Provider Demographics
NPI:1649947441
Name:BERNHAGEN, JACQUELINE ELISE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ELISE
Last Name:BERNHAGEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JACQUI
Other - Middle Name:ELISE
Other - Last Name:BERNHAGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1213 WHATCOM ST APT 119
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-5763
Mailing Address - Country:US
Mailing Address - Phone:918-720-4407
Mailing Address - Fax:
Practice Address - Street 1:456 C ST
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-4238
Practice Address - Country:US
Practice Address - Phone:360-332-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA201847167WAMedicaid