Healthcare Provider Details

I. General information

NPI: 1205219623
Provider Name (Legal Business Name): JENNIFER FAWN BERNARD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING BLVD NE PMG KASEMAN BEHAVIORAL MEDICINE
ALBUQUERQUE NM
87112-5046
US

IV. Provider business mailing address

PO BOX 26666 PRESBYTERIAN HEALTHCARE SERVICES
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5300
  • Fax: 505-291-2956
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1380
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: