Provider Demographics
NPI:1811092372
Name:BERGERON, JACQUELINE FRANCES
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:FRANCES
Last Name:BERGERON
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 1:412 PECAN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ROADS
Mailing Address - State:LA
Mailing Address - Zip Code:70760
Mailing Address - Country:US
Mailing Address - Phone:225-618-0635
Mailing Address - Fax:
Practice Address - Street 1:213 HOSPITAL RD
Practice Address - Street 2:WINN DIXIE PHARMACY #1572
Practice Address - City:NEW ROADS
Practice Address - State:LA
Practice Address - Zip Code:70760
Practice Address - Country:US
Practice Address - Phone:225-638-5151
Practice Address - Fax:225-638-5148
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1262455Medicaid
LA1262455Medicaid
1926091Medicare UPIN