Basic Information
| Provider Information | |||||||||
| NPI: | 1346841442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHONG | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687046 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 BROADWAY STE 530 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063862013 | ||||||||
| FaxNumber: | 2063862149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY61086635 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.