Provider Demographics
NPI:1922067354
Name:BERGH, JON CARSTEN (PT)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:CARSTEN
Last Name:BERGH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 W MARGARET AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555
Mailing Address - Country:US
Mailing Address - Phone:760-499-6965
Mailing Address - Fax:
Practice Address - Street 1:540 PERDEW
Practice Address - Street 2:SUITE C
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555
Practice Address - Country:US
Practice Address - Phone:760-446-3611
Practice Address - Fax:760-446-5811
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist