Provider Demographics
NPI:1114489804
Name:CANSECO, JORGE (LCSW)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:CANSECO
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 1:2677 ZOE AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-6995
Mailing Address - Country:US
Mailing Address - Phone:323-589-1902
Mailing Address - Fax:323-589-1805
Practice Address - Street 1:2677 ZOE AVE STE 120
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-6995
Practice Address - Country:US
Practice Address - Phone:323-589-1902
Practice Address - Fax:323-589-1805
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8592OtherBOARD OF BEHAVIORAL SCIENCES - LCSW