Provider Demographics
NPI:1457035842
Name:BERGSTEDT, JENNIFER RENEE
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENEE
Last Name:BERGSTEDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20378 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-9717
Mailing Address - Country:US
Mailing Address - Phone:419-579-0253
Mailing Address - Fax:
Practice Address - Street 1:20378 COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-9717
Practice Address - Country:US
Practice Address - Phone:419-579-0253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services