Provider Demographics
NPI:1093987166
Name:EDMONDSON, JACK DUANE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DUANE
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14207 KENDRA WAY
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3330
Mailing Address - Country:US
Mailing Address - Phone:858-748-7093
Mailing Address - Fax:
Practice Address - Street 1:14207 KENDRA WAY
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-3330
Practice Address - Country:US
Practice Address - Phone:858-748-7093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-29
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical