Provider Demographics
NPI:1508145509
Name:BERG, JENNIFER DIANE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3604
Mailing Address - Country:US
Mailing Address - Phone:209-328-0143
Mailing Address - Fax:
Practice Address - Street 1:4441 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:209-328-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA219668164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse