Provider Demographics
NPI:1871195602
Name:BERG, JAMIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 BINFORD ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-3034
Mailing Address - Country:US
Mailing Address - Phone:435-363-5351
Mailing Address - Fax:
Practice Address - Street 1:1425 S 1500 E
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1613
Practice Address - Country:US
Practice Address - Phone:385-519-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10466280-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist