Provider Demographics
NPI:1437395944
Name:BERGQUAM, JENNIFER RUTH (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RUTH
Last Name:BERGQUAM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:RUTH
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:8242 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270
Mailing Address - Country:US
Mailing Address - Phone:360-921-3358
Mailing Address - Fax:425-320-4091
Practice Address - Street 1:9623 32ND ST SE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258
Practice Address - Country:US
Practice Address - Phone:360-834-6964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60055734174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist