Provider Demographics
NPI:1972374718
Name:WANG, JIAYI
Entity type:Individual
Prefix:
First Name:JIAYI
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16787 BEACH BLVD # 264
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-4848
Mailing Address - Country:US
Mailing Address - Phone:562-314-9890
Mailing Address - Fax:
Practice Address - Street 1:18837 BROOKHURST ST STE 102
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7301
Practice Address - Country:US
Practice Address - Phone:562-314-9890
Practice Address - Fax:714-699-1536
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143105106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist