Provider Demographics
NPI:1215424361
Name:BERG (VORDERSTRASSE), JESSIKA MARY
Entity type:Individual
Prefix:
First Name:JESSIKA
Middle Name:MARY
Last Name:BERG (VORDERSTRASSE)
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JESSIKA
Other - Middle Name:MARY
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 S AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2553
Mailing Address - Country:US
Mailing Address - Phone:208-631-7358
Mailing Address - Fax:
Practice Address - Street 1:4305 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5506
Practice Address - Country:US
Practice Address - Phone:971-304-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-15
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health