Provider Demographics
NPI:1710335542
Name:KOMEJAN, JACK (LCSW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KOMEJAN
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 1:402 W DURHAM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2910
Mailing Address - Country:US
Mailing Address - Phone:650-218-8293
Mailing Address - Fax:
Practice Address - Street 1:34TH AND CIVIC CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4399
Practice Address - Country:US
Practice Address - Phone:215-590-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS0123391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALS012339OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES