Provider Demographics
NPI:1982286746
Name:BERG, JAKE E (DO)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:E
Last Name:BERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MATTHEW ST
Mailing Address - Street 2:OUTREACH/FERGUSON BUILDING
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750
Mailing Address - Country:US
Mailing Address - Phone:740-568-5669
Mailing Address - Fax:
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:OUTREACH/FERGUSON BUILDING
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-4575
Practice Address - Country:US
Practice Address - Phone:740-568-5669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.016875207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program