Provider Demographics
NPI:1861812737
Name:BERGSTEIN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BERGSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ABBOTT ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2350 BROADHOLLOW RD
Practice Address - Street 2:NOLD HALL
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-1006
Practice Address - Country:US
Practice Address - Phone:631-420-2539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0022222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer