Provider Demographics
NPI:1780249276
Name:BERNARD, JAMIE
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:
Last Name:BERNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:NY
Mailing Address - Zip Code:12189-3502
Mailing Address - Country:US
Mailing Address - Phone:518-248-2669
Mailing Address - Fax:
Practice Address - Street 1:803 1ST ST
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:NY
Practice Address - Zip Code:12189-3502
Practice Address - Country:US
Practice Address - Phone:518-248-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY687458194172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
5548566OtherASSIGNED FILING NUMBER WITH NEW YORK STATE