Provider Demographics
NPI:1720221757
Name:BERTASI, JENNIFER A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:A
Last Name:BERTASI
Suffix:
Gender:F
Credentials:LCSW
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 322
Mailing Address - Street 2:
Mailing Address - City:PINE LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30072-0322
Mailing Address - Country:US
Mailing Address - Phone:404-377-3010
Mailing Address - Fax:
Practice Address - Street 1:1935 CLIFF VALLEY WAY NE
Practice Address - Street 2:SUITE 119
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2435
Practice Address - Country:US
Practice Address - Phone:404-377-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0035911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical