Provider Demographics
NPI:1982865895
Name:BERGSTROM, JENNIFER EILEEN (SLP-CCC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:EILEEN
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:EILEEN
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:PO BOX 290370
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:954-262-4346
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:6100 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-4416
Practice Address - Country:US
Practice Address - Phone:954-262-7783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008016599235Z00000X
FLSA10370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist