Provider Demographics
NPI:1548890676
Name:KING, JEREMY MANG
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:MANG
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DUNG
Other - Middle Name:MANG
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1202 MORENA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3841
Mailing Address - Country:US
Mailing Address - Phone:619-507-9333
Mailing Address - Fax:
Practice Address - Street 1:1202 MORENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3841
Practice Address - Country:US
Practice Address - Phone:619-507-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator