Provider Demographics
NPI:1396450714
Name:EDWARDS, DEJSA (SUDRC)
Entity type:Individual
Prefix:
First Name:DEJSA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 HOTEL CIR N STE 314
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2803
Mailing Address - Country:US
Mailing Address - Phone:619-759-1548
Mailing Address - Fax:
Practice Address - Street 1:9920 PACIFIC HEIGHTS BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4396
Practice Address - Country:US
Practice Address - Phone:303-989-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2025-03-31
Deactivation Date:2023-12-18
Deactivation Code:
Reactivation Date:2023-12-29
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA19113101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator