Provider Demographics
NPI:1235366394
Name:BERGERON, JEAN L
Entity Type:Individual
Prefix:MR
First Name:JEAN
Middle Name:L
Last Name:BERGERON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JEAN
Other - Middle Name:L
Other - Last Name:BERGERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:823 ALLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-8803
Mailing Address - Country:US
Mailing Address - Phone:505-988-1774
Mailing Address - Fax:505-989-8655
Practice Address - Street 1:823 ALLENDALE ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-8803
Practice Address - Country:US
Practice Address - Phone:505-988-1774
Practice Address - Fax:505-989-8655
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4389101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor