Provider Demographics
NPI:1952689119
Name:BERGSTROM, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BERGSTROM
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 1:301 STRANDER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2971
Mailing Address - Country:US
Mailing Address - Phone:206-394-2100
Mailing Address - Fax:206-394-2100
Practice Address - Street 1:301 STRANDER BLVD
Practice Address - Street 2:T-0627
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2971
Practice Address - Country:US
Practice Address - Phone:206-394-2100
Practice Address - Fax:206-394-2100
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00065598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist