Provider Demographics
NPI:1538288998
Name:FERNANDEZ, JORGE LUIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:FERNANDEZ
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 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-385-5481
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1510 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4437
Practice Address - Country:US
Practice Address - Phone:209-574-1030
Practice Address - Fax:209-574-1038
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW19954101YP2500X
CALCS 292341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS 29234OtherLICENSE NUMBER