Provider Demographics
NPI:1598715336
Name:BERGSTROM, JACLYN MERRY (DC)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:MERRY
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 NE 132ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3014
Mailing Address - Country:US
Mailing Address - Phone:503-255-6771
Mailing Address - Fax:503-251-5794
Practice Address - Street 1:2900 NE 132ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-3014
Practice Address - Country:US
Practice Address - Phone:503-255-6771
Practice Address - Fax:503-251-5794
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND705111N00000X
MN4665111N00000X
OR5133111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN044057400Medicaid
NDU88525Medicare UPIN