Provider Demographics
NPI:1083883813
Name:BERGERON, JASON (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BERGERON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 TOWN FARM RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01506-1746
Mailing Address - Country:US
Mailing Address - Phone:508-867-2809
Mailing Address - Fax:
Practice Address - Street 1:400 W CUMMINGS PARK
Practice Address - Street 2:SUITE 3950
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6519
Practice Address - Country:US
Practice Address - Phone:781-933-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist