=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548475353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA AURORA BERRIO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7055 W BELL RD SUITE 21
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-8544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 632-878-2037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10486 N CANTERBURY DR
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-9305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-669-6104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 7656912-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------