Provider Demographics
NPI:1992814834
Name:DE JONG, ANNEMIEKE (PHD)
Entity type:Individual
Prefix:DR
First Name:ANNEMIEKE
Middle Name:
Last Name:DE JONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:DE JONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2171 UNION ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-4003
Mailing Address - Country:US
Mailing Address - Phone:415-346-8144
Mailing Address - Fax:
Practice Address - Street 1:2171 UNION ST
Practice Address - Street 2:SUITE 4
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4003
Practice Address - Country:US
Practice Address - Phone:415-346-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15584103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL155840OtherBLUE SHIELD
CA188081OtherMANAGED HEATLTH NETWORK