Provider Demographics
NPI:1063190080
Name:JERNICK, BRIAN MICHAEL JR (APN, CRNA)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:JERNICK
Suffix:JR
Gender:M
Credentials:APN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 VALLEY DR W
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07418-1812
Mailing Address - Country:US
Mailing Address - Phone:862-268-6477
Mailing Address - Fax:
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:800-843-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14873300367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered