Provider Demographics
NPI:1013936822
Name:DAVIDSON, JOLYN (RN, LCSW, DCSW)
Entity Type:Individual
Prefix:
First Name:JOLYN
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:RN, LCSW, DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 CENTER COURT DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3681
Mailing Address - Country:US
Mailing Address - Phone:626-339-2140
Mailing Address - Fax:
Practice Address - Street 1:1338 CENTER COURT DR
Practice Address - Street 2:SUITE 102
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3681
Practice Address - Country:US
Practice Address - Phone:626-339-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 93791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
954300079OtherTIN