Provider Demographics
NPI:1871959205
Name:BERGMAN, JEN
Entity type:Individual
Prefix:
First Name:JEN
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:
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 1565
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85244-1565
Mailing Address - Country:US
Mailing Address - Phone:480-241-3542
Mailing Address - Fax:480-888-9601
Practice Address - Street 1:784 NORTHRIDGE MALL
Practice Address - Street 2:SUITE #299
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-2015
Practice Address - Country:US
Practice Address - Phone:831-261-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64846172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver