Provider Demographics
NPI:1356688782
Name:BERG, JILL E (LAC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:BERG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72599 220TH ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-4913
Mailing Address - Country:US
Mailing Address - Phone:507-373-2678
Mailing Address - Fax:
Practice Address - Street 1:72599 220TH ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-4913
Practice Address - Country:US
Practice Address - Phone:507-373-2678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1623171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist