Provider Demographics
NPI:1922638113
Name:BERGEN, JAYNE
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:
Last Name:BERGEN
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 1:2091 GOLD RD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-6042
Mailing Address - Country:US
Mailing Address - Phone:352-346-4421
Mailing Address - Fax:
Practice Address - Street 1:8309 NORBERT ST
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-3144
Practice Address - Country:US
Practice Address - Phone:813-516-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider