Provider Demographics
NPI:1992049233
Name:BERTINO, JENNIFER ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BERTINO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:BERTINO POLIDORI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8211 W USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5756
Mailing Address - Country:US
Mailing Address - Phone:208-375-3700
Mailing Address - Fax:208-639-3048
Practice Address - Street 1:8211 W USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5756
Practice Address - Country:US
Practice Address - Phone:208-375-3700
Practice Address - Fax:208-639-3048
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1707235Z00000X
OR14042235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist