Provider Demographics
NPI:1295387876
Name:MEDINA, JOHARA (LMSW)
Entity Type:Individual
Prefix:
First Name:JOHARA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1839
Mailing Address - Country:US
Mailing Address - Phone:602-277-5551
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker