Provider Demographics
NPI:1376115774
Name:BERGMARK, JENNA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:BERGMARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 S LAS POSAS RD STE 254
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2475
Mailing Address - Country:US
Mailing Address - Phone:760-290-3121
Mailing Address - Fax:760-290-3126
Practice Address - Street 1:137 S LAS POSAS RD STE 254
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2475
Practice Address - Country:US
Practice Address - Phone:760-290-3121
Practice Address - Fax:760-290-3126
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist