Provider Demographics
NPI:1295276897
Name:BERGMAN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 NORTH BUXTON STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125
Mailing Address - Country:US
Mailing Address - Phone:515-358-7608
Mailing Address - Fax:
Practice Address - Street 1:1409 CLARK ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1964
Practice Address - Country:US
Practice Address - Phone:515-643-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083849101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health