Provider Demographics
NPI:1063473015
Name:JANE Y FONG, PHD & ASSOCIATES
Entity type:Organization
Organization Name:JANE Y FONG, PHD & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DIRECTOR/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JANE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-239-9595
Mailing Address - Street 1:1818 SPRING ST STE A
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-1617
Mailing Address - Country:US
Mailing Address - Phone:805-239-9595
Mailing Address - Fax:805-239-9119
Practice Address - Street 1:1818 SPRING ST STE A
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-1617
Practice Address - Country:US
Practice Address - Phone:805-239-9595
Practice Address - Fax:805-239-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15121103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17054Medicare PIN