Basic Information
| Provider Information | |||||||||
| NPI: | 1770705337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNDT | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LICSW & LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 SE 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557443615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183261274 | ||||||||
| FaxNumber: | 2183268255 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 SE 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557443615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183261274 | ||||||||
| FaxNumber: | 2183268255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 00563 | MN | N | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | 36 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 70235700 | 05 | MN | MEDICAID | 62-20162 | 01 | MN | UNITED BEHAVIORAL HEALTH | OTHER | 1009418 | 01 | MN | PREFERRED ONE | OTHER | 69264BE | 01 | MN | BCBS OF MINNESOTA | OTHER |