Basic Information
| Provider Information | |||||||||
| NPI: | 1083338602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | JODIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 PALM AVE APT 104 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941182566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099355079 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4150 CLEMENT ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941211563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152214810 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2022 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | P10310 | ID | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.