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General NPI Number Information
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NPI Number | 1477715340
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Entity Type | Individual
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Provider Name | JESSICA R POLK LCSW
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Gender | Female
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Dates
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Enumeration Date | 07/01/2008
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Last Update Date | 11/14/2016
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Provider Practice Location Address
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Address Line | 2010 E EL SEGUNDO BLVD
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City | COMPTON
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State | CA
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Zip | 90222-7109
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Country | US
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Telephone | 310-637-0917
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Fax | 310-637-0473
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Provider Business Mailing Address
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Address Line | 2610 INDUSTRY WAY
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City | LYNWOOD
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State | CA
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Zip | 90262-4283
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Country | US
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Telephone | 310-631-8004
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Fax | 310-637-0473
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW 74433
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License Number State | CA
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