Provider Demographics
NPI:1639687726
Name:JAGANNATH, NIRMALA (LCSW)
Entity Type:Individual
Prefix:
First Name:NIRMALA
Middle Name:
Last Name:JAGANNATH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 EOLUS AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1519
Mailing Address - Country:US
Mailing Address - Phone:760-613-2924
Mailing Address - Fax:
Practice Address - Street 1:1751 EOLUS AVE
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1519
Practice Address - Country:US
Practice Address - Phone:760-613-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW231831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical