Provider Demographics
NPI:1578942520
Name:FIELDS, BERNADETTE EVELYENNA I (MA)
Entity Type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:EVELYENNA
Last Name:FIELDS
Suffix:I
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 JACOB LOIS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-2970
Mailing Address - Country:US
Mailing Address - Phone:904-612-1470
Mailing Address - Fax:
Practice Address - Street 1:3606 JACOB LOIS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2970
Practice Address - Country:US
Practice Address - Phone:904-612-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL171M00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist