Provider Demographics
NPI:1508043555
Name:EDWARDS, JACQUELYN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JACQUELYNNE
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:4715 VIEWRIDGE AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1680
Mailing Address - Country:US
Mailing Address - Phone:800-257-8715
Mailing Address - Fax:800-819-1655
Practice Address - Street 1:5410 N BRAESWOOD BLVD
Practice Address - Street 2:APT 914
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-3200
Practice Address - Country:US
Practice Address - Phone:713-721-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX026771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical