Provider Demographics
NPI:1407907082
Name:MERGNER, JACKY EILEEN (OTRL)
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:EILEEN
Last Name:MERGNER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:JACKY
Other - Middle Name:EILEEN
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:402 MAPLE ST.
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56549
Mailing Address - Country:US
Mailing Address - Phone:218-486-5077
Mailing Address - Fax:
Practice Address - Street 1:921 43RD AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-5320
Practice Address - Country:US
Practice Address - Phone:701-793-3646
Practice Address - Fax:701-293-6892
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND816225XP0200X
MN102599225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26623OtherBCBS ND PROVIDER NUMBER
ND51032Medicaid