Healthcare Provider Details

I. General information

NPI: 1538288998
Provider Name (Legal Business Name): JORGE LUIS FERNANDEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 FLORIDA AVE
MODESTO CA
95350-4437
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-574-1030
  • Fax: 209-574-1038
Mailing address:
  • Phone: 209-385-5481
  • Fax: 209-383-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberASW19954
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 29234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: