Healthcare Provider Details

I. General information

NPI: 1821492307
Provider Name (Legal Business Name): JEFFREY DAUGHERTY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 E MCDOWELL RD
PHOENIX AZ
85008-7735
US

IV. Provider business mailing address

3003 N CENTRAL AVE STE 400
PHOENIX AZ
85012-2929
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 602-275-1355
Mailing address:
  • Phone: 602-685-6000
  • Fax: 602-265-6973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-10133
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: