Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 000030459N6 | OR |
NPI | 1013949676 |
---|---|
Provider Name | Ms. Jo Ann G. Berenbach |
First Address | Roseburg, OR 97470-6523 |
Second Address | Roseburg, OR 97470-6523 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 17/07/2007 |