Provider Demographics
NPI:1366118390
Name:FARRELL, JON (ASW)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:FARRELL
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:R
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ASW
Mailing Address - Street 1:1001 POTRERO AVE BLDG 5
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3518
Mailing Address - Country:US
Mailing Address - Phone:628-206-4444
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE BLDG 5
Practice Address - Street 2:SUITE 6B
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95857101Y00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor