Provider Demographics
NPI:1417324096
Name:BERGERON, JESSICA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 CHARLES BANCROFT HWY
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03052-2600
Mailing Address - Country:US
Mailing Address - Phone:603-889-3451
Mailing Address - Fax:
Practice Address - Street 1:69 CHARLES BANCROFT HWY
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:NH
Practice Address - Zip Code:03052-2600
Practice Address - Country:US
Practice Address - Phone:603-889-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-30
Last Update Date:2015-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0888235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist