Provider Demographics
NPI:1407289978
Name:BERUMEN, JACQUELYN DIANE (PHM, CMS)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DIANE
Last Name:BERUMEN
Suffix:
Gender:F
Credentials:PHM, CMS
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:DIANE
Other - Last Name:WILLIFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-3302
Mailing Address - Country:US
Mailing Address - Phone:661-868-0505
Mailing Address - Fax:
Practice Address - Street 1:1800 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-3302
Practice Address - Country:US
Practice Address - Phone:661-868-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHM2100246QM0900X
CAMTE959246QM0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMicrobiology