Healthcare Provider Details

I. General information

NPI: 1790456812
Provider Name (Legal Business Name): JENNIFER L BERNINI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 E GRAND AVE
BELOIT WI
53511-6314
US

IV. Provider business mailing address

540 E GRAND AVE
BELOIT WI
53511-6314
US

V. Phone/Fax

Practice location:
  • Phone: 608-368-8087
  • Fax:
Mailing address:
  • Phone: 608-268-8087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19601-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11384-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: