Provider Demographics
NPI:1417928227
Name:SULLIVAN, JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7564 WINDY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 S JUNIPER ST
Practice Address - Street 2:STE 205
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4229
Practice Address - Country:US
Practice Address - Phone:858-381-5725
Practice Address - Fax:858-433-4100
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1255103TC0700X
CA24238103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical