Provider Demographics
NPI:1063041705
Name:BERG, JESSICA JO
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JO
Last Name:BERG
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 1:203 PARK AVE S STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-6216
Mailing Address - Country:US
Mailing Address - Phone:320-253-5650
Mailing Address - Fax:320-253-9222
Practice Address - Street 1:203 PARK AVE S STE 101
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6216
Practice Address - Country:US
Practice Address - Phone:320-253-5650
Practice Address - Fax:320-253-9222
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2020-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist