Provider Demographics
NPI:1184178378
Name:JASSO-NUNEZ, BERTHA
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:JASSO-NUNEZ
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 1:17124 INGLESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3506
Mailing Address - Country:US
Mailing Address - Phone:773-621-9289
Mailing Address - Fax:
Practice Address - Street 1:17124 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-3506
Practice Address - Country:US
Practice Address - Phone:773-621-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency