Basic Information
| Provider Information | |||||||||
| NPI: | 1235564352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTOLATUS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RISHAVY | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1585 RICE STREET | ||||||||
| Address2: | |||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514878088 | ||||||||
| FaxNumber: | 6514878105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1585 RICE STREET | ||||||||
| Address2: | |||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514878088 | ||||||||
| FaxNumber: | 6514878105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CC00477 | MN | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.