Provider Demographics
NPI:1669848180
Name:BERTOVICH, JENNIFER ANNE-LIEBERSBACH (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE-LIEBERSBACH
Last Name:BERTOVICH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:LIEBERSBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3336
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340
Mailing Address - Country:US
Mailing Address - Phone:775-303-8005
Mailing Address - Fax:
Practice Address - Street 1:630 SUN VALLEY RD. STE D102
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:775-303-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1880111N00000X
CA33042111NN1001X, 111NP0017X, 111NR0400X, 111NS0005X, 111NX0800X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0800XChiropractic ProvidersChiropractorOrthopedic