Provider Demographics
NPI:1447565445
Name:BERGERON, JASON P SR (PD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:BERGERON
Suffix:SR
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 W TUNNEL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2738
Mailing Address - Country:US
Mailing Address - Phone:985-223-2945
Mailing Address - Fax:985-223-8975
Practice Address - Street 1:1435 W TUNNEL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2738
Practice Address - Country:US
Practice Address - Phone:985-223-2945
Practice Address - Fax:985-223-8975
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist