Provider Demographics
NPI:1104171321
Name:BERTOLON, JENNIFER ROSE (CPNP, RN)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ROSE
Last Name:BERTOLON
Suffix:
Gender:F
Credentials:CPNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1275
Mailing Address - Country:US
Mailing Address - Phone:978-618-0239
Mailing Address - Fax:
Practice Address - Street 1:245 DODGE ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1275
Practice Address - Country:US
Practice Address - Phone:978-618-0239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-14
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2269678163WP0200X
MA20121422363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics