Provider Demographics
NPI:1891271706
Name:BERGEN, JACOB ALOYSIUS
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALOYSIUS
Last Name:BERGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38284 KLARR DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-9324
Mailing Address - Country:US
Mailing Address - Phone:248-756-5078
Mailing Address - Fax:
Practice Address - Street 1:17200 W OUTER DR STE A
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2457
Practice Address - Country:US
Practice Address - Phone:248-712-4266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401002142103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst