Provider Demographics
NPI:1568422707
Name:BERGERON, JON A JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:A
Last Name:BERGERON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16741 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8273
Mailing Address - Country:US
Mailing Address - Phone:979-575-5198
Mailing Address - Fax:
Practice Address - Street 1:16741 WOODLAKE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8273
Practice Address - Country:US
Practice Address - Phone:979-575-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31998103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1596470-01Medicaid
TXP00028151OtherRR/MEDICARE
TX86790AOtherBLUE SHIELD
TX86790AOtherBLUE SHIELD
TX8A7573Medicare ID - Type Unspecified