Provider Demographics
NPI:1205219623
Name:BERNARD, JENNIFER FAWN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:FAWN
Last Name:BERNARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PRESBYTERIAN HEALTHCARE SERVICES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:1325 WYOMING BLVD NE
Practice Address - Street 2:PMG KASEMAN BEHAVIORAL MEDICINE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5046
Practice Address - Country:US
Practice Address - Phone:505-291-5300
Practice Address - Fax:505-291-2956
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1380103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical