Provider Demographics
NPI:1073683140
Name:BERGDEN, JESSICA SUZANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:SUZANNE
Last Name:BERGDEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 WARWICK AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3657
Mailing Address - Country:US
Mailing Address - Phone:401-461-2707
Mailing Address - Fax:401-461-2708
Practice Address - Street 1:1045 WARWICK AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3657
Practice Address - Country:US
Practice Address - Phone:401-461-2707
Practice Address - Fax:401-461-2708
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDC00417111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI21678-0OtherBLUE CROSS & BLUE SHIELD
RI408582OtherBLUE CHIP