MEDICARE: MS. JENNIFER A BERTASI LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW003591	GA

General Provider Information

NPI Number	:	1720221757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER A BERTASI LCSW

Provider Business Mailing Address
First Line	:	PO BOX 322
Second Line	:
City	:	PINE LAKE
State	:	GA
Zip	:	30072-0322
Country	:	US
Telephone Number	:	404-377-3010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 CLIFF VALLEY WAY NE
Second Line	:	SUITE 119
City	:	ATLANTA
State	:	GA
Zip	:	30329-2435
Country	:	US
Telephone Number	:	404-377-3010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2009
Last Update Date	:	04/06/2009

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