Healthcare Provider Details

I. General information

NPI: 1366118390
Provider Name (Legal Business Name): JON FARRELL ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JONATHAN R FARRELL ASW

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE BLDG 5 SUITE 6B
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

1001 POTRERO AVE BLDG 5 SUITE 6B
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-4444
  • Fax:
Mailing address:
  • Phone: 628-206-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number95857
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number95857
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: