Provider Demographics
NPI:1679663181
Name:MADGULKAR, JAIDEV (LCSW)
Entity Type:Individual
Prefix:
First Name:JAIDEV
Middle Name:
Last Name:MADGULKAR
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 1:12625 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7720
Mailing Address - Country:US
Mailing Address - Phone:760-955-1777
Mailing Address - Fax:760-955-2356
Practice Address - Street 1:12625 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7720
Practice Address - Country:US
Practice Address - Phone:760-955-1777
Practice Address - Fax:760-955-2356
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS161481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical