Provider Demographics
NPI:1487020699
Name:DIBERT, JENNIFER MARY (BA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARY
Last Name:DIBERT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 WHEATON WAY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3565
Mailing Address - Country:US
Mailing Address - Phone:360-362-8635
Mailing Address - Fax:
Practice Address - Street 1:4040 WHEATON WAY
Practice Address - Street 2:SUITE 112
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311
Practice Address - Country:US
Practice Address - Phone:360-362-8635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60577370101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health