Provider Demographics
NPI:1710939814
Name:CARLSON, JENNIFER BERGERON (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BERGERON
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ELLEN
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:52 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7204
Mailing Address - Country:US
Mailing Address - Phone:802-658-2320
Mailing Address - Fax:
Practice Address - Street 1:52 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7204
Practice Address - Country:US
Practice Address - Phone:802-658-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5758864-1205208000000X, 2080P0204X
VT042-0011786208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine