Provider Demographics
NPI:1396498572
Name:BERGSTROM, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:PERRIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14619 RACE ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-7006
Mailing Address - Country:US
Mailing Address - Phone:617-224-7583
Mailing Address - Fax:
Practice Address - Street 1:8510 BRYANT ST STE 360
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3852
Practice Address - Country:US
Practice Address - Phone:720-798-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician