Provider Demographics
NPI:1124823018
Name:BERNARD, JEAN WALACE
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:WALACE
Last Name:BERNARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 LAWRENCE ST FL 2
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-5132
Mailing Address - Country:US
Mailing Address - Phone:908-630-8928
Mailing Address - Fax:
Practice Address - Street 1:1436 LAWRENCE ST FL 2
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-5132
Practice Address - Country:US
Practice Address - Phone:908-630-8928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-15
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver