Basic Information
| Provider Information | |||||||||
| NPI: | 1538288998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | LUIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093855481 | ||||||||
| FaxNumber: | 2093831296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095741030 | ||||||||
| FaxNumber: | 2095741038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 06/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | ASW19954 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | LCS 29234 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LCS 29234 | 01 | CA | LICENSE NUMBER | OTHER |