Provider Demographics
NPI:1922262591
Name:BERGERON, MARTHA JACKSON (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JACKSON
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MILFORD ST
Mailing Address - Street 2:
Mailing Address - City:UPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01568-1309
Mailing Address - Country:US
Mailing Address - Phone:508-529-7000
Mailing Address - Fax:
Practice Address - Street 1:206 MILFORD ST
Practice Address - Street 2:
Practice Address - City:UPTON
Practice Address - State:MA
Practice Address - Zip Code:01568-1309
Practice Address - Country:US
Practice Address - Phone:508-529-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214911104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker