Provider Demographics
NPI:1750941779
Name:BERGSTROM, JORDAN LEIGH (AUD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEIGH
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LEIGH
Other - Last Name:HOFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1753 FULTON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1927
Practice Address - Country:US
Practice Address - Phone:574-293-9448
Practice Address - Fax:574-293-9480
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002688A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300027641Medicaid