Provider Demographics
NPI:1235395690
Name:BERGSTROM, JAN MICHELE (LMHC)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:MICHELE
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-8531
Mailing Address - Country:US
Mailing Address - Phone:781-777-1172
Mailing Address - Fax:781-777-1108
Practice Address - Street 1:21 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-8531
Practice Address - Country:US
Practice Address - Phone:781-777-1172
Practice Address - Fax:781-777-1108
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4548101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor