Provider Demographics
NPI:1851869689
Name:BERGQUIST, JESSICA DANIELLE (RBT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DANIELLE
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:DANIELLE
Other - Last Name:PINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1991 CAROUSEL DR
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5660
Mailing Address - Country:US
Mailing Address - Phone:831-444-1760
Mailing Address - Fax:
Practice Address - Street 1:1485 SARATOGA AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4965
Practice Address - Country:US
Practice Address - Phone:877-991-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician