Basic Information
Provider Information | |||||||||
NPI: | 1073068417 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JERNIGAN | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MFT INTERN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 271 | ||||||||
Address2: |   | ||||||||
City: | HYDESVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 955470271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3000 NEWBURG RD STE D | ||||||||
Address2: |   | ||||||||
City: | FORTUNA | ||||||||
State: | CA | ||||||||
PostalCode: | 955402522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7072688722 | ||||||||
FaxNumber: | 7072680218 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2016 | ||||||||
LastUpdateDate: | 08/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 120558 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 101YM0800X | 93764 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.