Healthcare Provider Details

I. General information

NPI: 1487711446
Provider Name (Legal Business Name): FERNANDO FAJARDO JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612-4745
US

IV. Provider business mailing address

PO BOX 261256
TAMPA FL
33685-1256
US

V. Phone/Fax

Practice location:
  • Phone: 813-347-2999
  • Fax:
Mailing address:
  • Phone: 813-267-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8477
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: