Provider Demographics
NPI:1558562199
Name:JENNIFER BERGMAN MS CCC LLC
Entity Type:Organization
Organization Name:JENNIFER BERGMAN MS CCC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:856-983-6160
Mailing Address - Street 1:475 OLD MARLTON PIKE W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2098
Mailing Address - Country:US
Mailing Address - Phone:856-983-6160
Mailing Address - Fax:
Practice Address - Street 1:475 OLD MARLTON PIKE W
Practice Address - Street 2:SUITE 1
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2098
Practice Address - Country:US
Practice Address - Phone:856-983-6160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00090300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ41YS00090300OtherLICENSE