Provider Demographics
NPI:1538587175
Name:WONG, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WONG
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 1:420 DELAWARE ST SE
Mailing Address - Street 2:PHILLIPS WANGENSTEEN BLDG, 14TH FLOOR, SUITE 100
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-626-5031
Mailing Address - Fax:612-625-3238
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:PHILLIPS WANGENSTEEN BLDG, 14TH FLOOR, SUITE 100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-626-5031
Practice Address - Fax:612-625-3238
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-01
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN63365207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program