Provider Demographics
NPI:1134771652
Name:BERG, JESSIE ALAN (RBT)
Entity type:Individual
Prefix:MR
First Name:JESSIE
Middle Name:ALAN
Last Name:BERG
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 KEMPSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2617
Mailing Address - Country:US
Mailing Address - Phone:757-403-0661
Mailing Address - Fax:
Practice Address - Street 1:2008 GENERAL BOOTH BLVD STE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5910
Practice Address - Country:US
Practice Address - Phone:757-301-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-91373106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician