Provider Demographics
NPI:1962149823
Name:BERTAGNOLE, JENNIFER (CPM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BERTAGNOLE
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1674
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1674
Mailing Address - Country:US
Mailing Address - Phone:801-695-5134
Mailing Address - Fax:
Practice Address - Street 1:993 S 800 W
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84087-2056
Practice Address - Country:US
Practice Address - Phone:801-695-5134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9585456-3400176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife