Healthcare Provider Details

I. General information

NPI: 1477715340
Provider Name (Legal Business Name): JESSICA R POLK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 E EL SEGUNDO BLVD
COMPTON CA
90222-7109
US

IV. Provider business mailing address

2610 INDUSTRY WAY
LYNWOOD CA
90262-4283
US

V. Phone/Fax

Practice location:
  • Phone: 310-637-0917
  • Fax: 310-637-0473
Mailing address:
  • Phone: 310-631-8004
  • Fax: 310-637-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 74433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: