Basic Information
| Provider Information | |||||||||
| NPI: | 1033455027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3051 WATSON BLVD STE 525 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3051 WATSON BLVD STE 525 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534564 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2012 | ||||||||
| LastUpdateDate: | 03/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC012643 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | U1-0001457 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT006093 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.