Provider Demographics
NPI:1982303103
Name:BERGQUIST, JACQUELINE LYNN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LYNN
Last Name:BERGQUIST
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 1:4111 BRADLEY CIR NW STE 150
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2563
Mailing Address - Country:US
Mailing Address - Phone:330-546-0199
Mailing Address - Fax:330-546-0186
Practice Address - Street 1:4111 BRADLEY CIR NW STE 150
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2563
Practice Address - Country:US
Practice Address - Phone:330-546-0199
Practice Address - Fax:330-546-0186
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW.2200319171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator