Provider Demographics
NPI:1831587872
Name:FAZEL, JILLIAN (LCSW)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:FAZEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:SHIVELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:602-470-5064
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0990
Practice Address - Fax:602-933-4251
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-140901041C0700X
AZLCSW-178021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical