Healthcare Provider Details

I. General information

NPI: 1104222835
Provider Name (Legal Business Name): JEANETTE BERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 Z ST
HEYBURN ID
83336-7650
US

IV. Provider business mailing address

2031 Z ST
HEYBURN ID
83336-7650
US

V. Phone/Fax

Practice location:
  • Phone: 208-260-1212
  • Fax:
Mailing address:
  • Phone: 208-260-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6752
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: