Provider Demographics
NPI:1871590117
Name:JERNBERG, EMILY RUTH (PH D)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:RUTH
Last Name:JERNBERG
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:#202
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1768
Mailing Address - Country:US
Mailing Address - Phone:248-505-4161
Mailing Address - Fax:248-601-9991
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:#202
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:248-505-4161
Practice Address - Fax:248-601-9991
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008691103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3959Medicare PIN