Provider Demographics
NPI:1073068417
Name:JERNIGAN, REBECCA (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:MFT INTERN
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 271
Mailing Address - Street 2:
Mailing Address - City:HYDESVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95547-0271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 NEWBURG RD STE D
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2522
Practice Address - Country:US
Practice Address - Phone:707-268-8722
Practice Address - Fax:707-268-0218
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120558106H00000X
CA93764101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health