Provider Demographics
NPI:1043538770
Name:WANG, JADELYN THANH (LMFT)
Entity type:Individual
Prefix:
First Name:JADELYN
Middle Name:THANH
Last Name:WANG
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MORENA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3844
Mailing Address - Country:US
Mailing Address - Phone:619-276-8112
Mailing Address - Fax:
Practice Address - Street 1:15525 POMERADO RD STE B3
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2425
Practice Address - Country:US
Practice Address - Phone:760-547-3152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X, 106H00000X
CA107850106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness