Healthcare Provider Details

I. General information

NPI: 1104171321
Provider Name (Legal Business Name): JENNIFER ROSE BERTOLON CPNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2012
Last Update Date: 07/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 DODGE ST
BEVERLY MA
01915-1275
US

IV. Provider business mailing address

245 DODGE ST
BEVERLY MA
01915-1275
US

V. Phone/Fax

Practice location:
  • Phone: 978-618-0239
  • Fax:
Mailing address:
  • Phone: 978-618-0239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN2269678
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20121422
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: