Provider Demographics
NPI:1770705337
Name:BERNDT, JEROME C (LICSW & LMFT)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:C
Last Name:BERNDT
Suffix:
Gender:M
Credentials:LICSW & LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3615
Mailing Address - Country:US
Mailing Address - Phone:218-326-1274
Mailing Address - Fax:218-326-8255
Practice Address - Street 1:215 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3615
Practice Address - Country:US
Practice Address - Phone:218-326-1274
Practice Address - Fax:218-326-8255
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00563104100000X
MN36106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN70235700Medicaid
MN62-20162OtherUNITED BEHAVIORAL HEALTH
MN1009418OtherPREFERRED ONE
MN69264BEOtherBCBS OF MINNESOTA