Provider Demographics
NPI:1023225273
Name:JOGOPULOS, MICHAEL G (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:JOGOPULOS
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 1:2101 COURAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6717
Mailing Address - Country:US
Mailing Address - Phone:707-784-8216
Mailing Address - Fax:707-427-2981
Practice Address - Street 1:275 BECK AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6804
Practice Address - Country:US
Practice Address - Phone:707-784-8216
Practice Address - Fax:707-425-4230
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 209381041C0700X
CA20938104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical