Provider Demographics
NPI:1659462091
Name:BJERKE, MARK D (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BJERKE
Suffix:
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 1:826 S HASTINGS WAY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3426
Mailing Address - Country:US
Mailing Address - Phone:715-834-3171
Mailing Address - Fax:715-834-3174
Practice Address - Street 1:826 S HASTINGS WAY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3426
Practice Address - Country:US
Practice Address - Phone:715-834-3171
Practice Address - Fax:715-834-3174
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2294-057103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39132300Medicaid
WI39132300Medicaid