Basic Information
| Provider Information | |||||||||
| NPI: | 1902978463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZWASKA | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 W GLENDALE AVE | ||||||||
| Address2: | E119 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850518194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239150270 | ||||||||
| FaxNumber: | 6239154837 | ||||||||
| Practice Location | |||||||||
| Address1: | 4620 N 16TH ST | ||||||||
| Address2: | E110 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850165121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239150270 | ||||||||
| FaxNumber: | 6239154837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SW-1333I | AZ | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 818362 | 05 | AZ | MEDICAID |