Provider Demographics
NPI:1609575935
Name:BERG, JENNIFER MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BERG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DR BERG
Mailing Address - Street 1:5266 N COLONIAL AVE APT A
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-2337
Mailing Address - Country:US
Mailing Address - Phone:559-665-5531
Mailing Address - Fax:
Practice Address - Street 1:23370 ROAD 22
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-8504
Practice Address - Country:US
Practice Address - Phone:559-665-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32857103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY32857OtherCA CLINICAL PSYCHOLOGIST LICENSE