Provider Demographics
NPI:1679926091
Name:JALILI, FARY
Entity Type:Individual
Prefix:
First Name:FARY
Middle Name:
Last Name:JALILI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FARZANEH
Other - Middle Name:
Other - Last Name:JALILI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4635 THOMAS LAKE HARRIS DR UNIT 318
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0195
Mailing Address - Country:US
Mailing Address - Phone:917-574-1933
Mailing Address - Fax:
Practice Address - Street 1:4635 THOMAS LAKE HARRIS DR UNIT 318
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-0195
Practice Address - Country:US
Practice Address - Phone:917-574-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1189561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical