Provider Demographics
NPI:1558062448
Name:BERG, JAMIE (LLPC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 WASHINGTON BLVD APT 2615
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1730
Mailing Address - Country:US
Mailing Address - Phone:239-322-0469
Mailing Address - Fax:
Practice Address - Street 1:89 E EDSEL FORD FWY STE 200
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3742
Practice Address - Country:US
Practice Address - Phone:313-288-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022703101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health