Healthcare Provider Details

I. General information

NPI: 1497395073
Provider Name (Legal Business Name): SASHA MARIE MEDOFF JAY ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 05/02/2021
Certification Date: 05/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3731 6TH AVE STE 100
SAN DIEGO CA
92103-4383
US

IV. Provider business mailing address

3002 ARMSTRONG ST
SAN DIEGO CA
92111-5702
US

V. Phone/Fax

Practice location:
  • Phone: 619-278-0884
  • Fax:
Mailing address:
  • Phone: 858-633-4106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW93062
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: