Basic Information
| Provider Information | |||||||||
| NPI: | 1396775888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERMUDEZ | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 367 S. GULPH RD | ||||||||
| Address2: | ATT: IPM CREDENTIALING | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753569393 | ||||||||
| FaxNumber: | 7753565590 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 2ND ST E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417465111 | ||||||||
| FaxNumber: | 9417457233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | NC200401025 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | ME87766 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 53444 | 01 | FL | BCBS | OTHER | 275481900 | 05 | FL | MEDICAID |