| Doctor Name: | JACK DUANE EDMONDSON |
| NPI Number: | 1093987166 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | 1903 |
| Business Practice Address: | 14207 Kendra Way Poway, CA - 920643330 |
| Business Phone Number: | 8587487093 |
| Business Fax Number: | |
| Mailing Address: | 14207 Kendra Way, POWAY |
| State: | CA |
| Postal Code: | 920643330 |
| Phone Number: | 8587487093 |
| Fax Number: | |
| NPI Enumeration Date: | 03/29/2008 |
| NPI Last Update Date: | 03/29/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 1903 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |