Provider Demographics
NPI:1427215631
Name:BERGMAN, JASON NATHANIEL (DAC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:NATHANIEL
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 TRANSIT STREET
Mailing Address - Street 2:APT 3
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-523-3253
Mailing Address - Fax:
Practice Address - Street 1:172 BROADWAY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-3014
Practice Address - Country:US
Practice Address - Phone:401-523-3253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDA00312171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist