Provider Demographics
NPI:1588978100
Name:WONG-POWELL, JEANNETTE AIDEE (OD)
Entity type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:AIDEE
Last Name:WONG-POWELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JEANNETTE
Other - Middle Name:AIDEE
Other - Last Name:WONG AMIEVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1252 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-3509
Mailing Address - Country:US
Mailing Address - Phone:210-724-4849
Mailing Address - Fax:830-629-4089
Practice Address - Street 1:9725 DATAPOINT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2384
Practice Address - Country:US
Practice Address - Phone:210-883-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7620T152W00000X
IN18003668A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist