Provider Demographics
NPI:1639991524
Name:BERBERICH, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BERBERICH
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 1:604 W CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56087-1114
Mailing Address - Country:US
Mailing Address - Phone:507-822-0295
Mailing Address - Fax:
Practice Address - Street 1:621 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LE SUEUR
Practice Address - State:MN
Practice Address - Zip Code:56058-2203
Practice Address - Country:US
Practice Address - Phone:507-822-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2948225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant