Provider Demographics
NPI:1003574971
Name:BERGUM, JAXON
Entity Type:Individual
Prefix:
First Name:JAXON
Middle Name:
Last Name:BERGUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-2408
Mailing Address - Country:US
Mailing Address - Phone:701-795-9143
Mailing Address - Fax:
Practice Address - Street 1:930 N 3RD ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-2408
Practice Address - Country:US
Practice Address - Phone:701-795-9143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10586247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other