Provider Demographics
NPI:1255217998
Name:BERGSTROM, JACOB (LPCC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 N CLARKSON ST APT 303
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1853
Mailing Address - Country:US
Mailing Address - Phone:714-797-0798
Mailing Address - Fax:
Practice Address - Street 1:295 INTERLOCKEN BLVD STE 400
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-8105
Practice Address - Country:US
Practice Address - Phone:720-853-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACA.0008282101YA0400X
COLPCC.0023748101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)