Provider Demographics
NPI:1558840850
Name:BERGSTROM, JEFFREY ROBERT (ACSW LMSW MPA RADT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:ACSW LMSW MPA RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:MULLAN
Mailing Address - State:ID
Mailing Address - Zip Code:83846-0444
Mailing Address - Country:US
Mailing Address - Phone:208-446-6758
Mailing Address - Fax:
Practice Address - Street 1:1950 W ROOSEVELT HWY
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-1549
Practice Address - Country:US
Practice Address - Phone:406-434-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1009631041C0700X
HI46861041C0700X
ID407571041C0700X
MT499931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical