Provider Demographics
NPI:1932696192
Name:AVALOS, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:AVALOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 3RD AVE STE 1110
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1350
Mailing Address - Country:US
Mailing Address - Phone:619-934-5770
Mailing Address - Fax:619-391-0091
Practice Address - Street 1:855 3RD AVE STE 1110
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1350
Practice Address - Country:US
Practice Address - Phone:619-934-5770
Practice Address - Fax:619-391-0091
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA973561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical