Provider Demographics
NPI:1750668141
Name:BERGLUND, JASON R (ATC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:BERGLUND
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 TACOMA MALL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6828
Mailing Address - Country:US
Mailing Address - Phone:253-851-5200
Mailing Address - Fax:
Practice Address - Street 1:6050 TACOMA MALL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-6828
Practice Address - Country:US
Practice Address - Phone:253-851-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002146A2255A2300X
IL096.0026612255A2300X
WAA1605901122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA160590112OtherWASHINGTON STATE DEPARTMENT OF HEALTH - ATHLETIC TRAINER LICENSE
090702258OtherBOARD OF CERTIFICATION, INC. (NATA)
IN36002146AOtherINDIANA PROFESSIONAL LICENSING AGENCY ATHLETIC TRAINERS BOARD
IL096.002661OtherSTATE OF ILLINOIS - DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION