Provider Demographics
NPI:1124181292
Name:BERGERON, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
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 1:69 ROCCO DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:MA
Mailing Address - Zip Code:01504-1373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 COLLYER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1869
Practice Address - Country:US
Practice Address - Phone:401-793-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT00440225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist