Healthcare Provider Details

I. General information

NPI: 1073068417
Provider Name (Legal Business Name): REBECCA JERNIGAN MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEWBURG RD STE D
FORTUNA CA
95540-2522
US

IV. Provider business mailing address

PO BOX 271
HYDESVILLE CA
95547-0271
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-8722
  • Fax: 707-268-0218
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120558
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number93764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: