MEDICARE: MS. MARYJANE EVANS ASW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	ASW15563	CA

General Provider Information

NPI Number	:	1457482572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARYJANE EVANS ASW

Provider Business Mailing Address
First Line	:	4707 55TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-2202
Country	:	US
Telephone Number	:	619-528-8005
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 S MAGNOLIA AVE STE 302
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-5224
Country	:	US
Telephone Number	:	619-442-5434
Fax Number	:	619-442-5451

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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