Provider Demographics
NPI:1548573645
Name:BERGMANN, JENNIFER LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:BERGMANN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:COUGHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1 CHARCOAL RD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-4013
Mailing Address - Country:US
Mailing Address - Phone:214-629-5906
Mailing Address - Fax:
Practice Address - Street 1:4155 CESAR CHAVEZ ST
Practice Address - Street 2:#6
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-1957
Practice Address - Country:US
Practice Address - Phone:214-629-5906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-17
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TA0400X
NY022176103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)