Healthcare Provider Details

I. General information

NPI: 1194965483
Provider Name (Legal Business Name): IRENA C FAJARDO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE BOX 359760
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

325 9TH AVE
SEATTLE WA
98104-2420
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-5604
  • Fax: 206-744-4505
Mailing address:
  • Phone: 206-257-0608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00009686
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: