Provider Demographics
NPI:1104222835
Name:BERN, JEANETTE
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:BERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 N 100 E
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-9341
Mailing Address - Country:US
Mailing Address - Phone:208-260-1212
Mailing Address - Fax:
Practice Address - Street 1:940 N 100 E
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-9341
Practice Address - Country:US
Practice Address - Phone:208-260-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5532101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional