Provider Demographics
NPI:1811203912
Name:JAMESON, EDNA
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:JAMESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E TONTO ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-4032
Mailing Address - Country:US
Mailing Address - Phone:602-241-6656
Mailing Address - Fax:602-241-7506
Practice Address - Street 1:1107 E TONTO ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-4032
Practice Address - Country:US
Practice Address - Phone:602-241-6656
Practice Address - Fax:602-241-7506
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW111801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical