Provider Demographics
NPI:1508506072
Name:AUDREY SOPHIA JARAHZADEH, LICENSED CLINICAL SOCIAL WORKER, P.C
Entity Type:Organization
Organization Name:AUDREY SOPHIA JARAHZADEH, LICENSED CLINICAL SOCIAL WORKER, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JARAHZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-770-2431
Mailing Address - Street 1:9740 CAMPO RD STE 1015
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1415
Mailing Address - Country:US
Mailing Address - Phone:310-770-2431
Mailing Address - Fax:
Practice Address - Street 1:1901 1ST AVE STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-0300
Practice Address - Country:US
Practice Address - Phone:310-770-2431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-31
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty