Provider Demographics
NPI:1407862436
Name:ERTL, JEAN MAIRE (LCSW, ACSW)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MAIRE
Last Name:ERTL
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4852 LILA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1910
Mailing Address - Country:US
Mailing Address - Phone:619-286-2687
Mailing Address - Fax:619-286-2687
Practice Address - Street 1:8810 RIO SAN DIEGO DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1622
Practice Address - Country:US
Practice Address - Phone:619-400-5181
Practice Address - Fax:619-400-5154
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS130291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical