Provider Demographics
NPI:1255031506
Name:BERGNER, JILL MARIE (NCTMB, WLMT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:BERGNER
Suffix:
Gender:F
Credentials:NCTMB, WLMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4838 ELM RD
Mailing Address - Street 2:
Mailing Address - City:KRAKOW
Mailing Address - State:WI
Mailing Address - Zip Code:54137-9026
Mailing Address - Country:US
Mailing Address - Phone:920-606-0277
Mailing Address - Fax:
Practice Address - Street 1:N4838 ELM RD
Practice Address - Street 2:
Practice Address - City:KRAKOW
Practice Address - State:WI
Practice Address - Zip Code:54137-9026
Practice Address - Country:US
Practice Address - Phone:920-606-0277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2632146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist