Healthcare Provider Details

I. General information

NPI: 1922632231
Provider Name (Legal Business Name): JASON JOSEPH IANNELLO ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 OBERLIN DR STE 300
SAN DIEGO CA
92121-4717
US

IV. Provider business mailing address

1301 E ORANGEWOOD AVE
ANAHEIM CA
92805-6807
US

V. Phone/Fax

Practice location:
  • Phone: 800-249-1266
  • Fax:
Mailing address:
  • Phone: 800-249-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW139512
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: