Provider Demographics
NPI:1245389212
Name:CORRALES, JESUS ERNESTO (MFT)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ERNESTO
Last Name:CORRALES
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122279
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911
Mailing Address - Country:US
Mailing Address - Phone:619-691-1880
Mailing Address - Fax:619-691-5937
Practice Address - Street 1:815 3RD AVE
Practice Address - Street 2:#319
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911
Practice Address - Country:US
Practice Address - Phone:619-691-1880
Practice Address - Fax:619-691-5937
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27099106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist