Provider Demographics
NPI:1477014439
Name:BERGES, JENNIE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:BERGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:CUMMINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 231
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-0231
Mailing Address - Country:US
Mailing Address - Phone:631-909-9247
Mailing Address - Fax:
Practice Address - Street 1:49 LANDING AVE STE 2
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2750
Practice Address - Country:US
Practice Address - Phone:631-909-9247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009067101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health