Provider Demographics
NPI:1386935641
Name:BERG, JACQUELINE LEIGH (MS, MA, LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEIGH
Last Name:BERG
Suffix:
Gender:F
Credentials:MS, MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 UNION AVE, #5
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246
Mailing Address - Country:US
Mailing Address - Phone:603-387-1523
Mailing Address - Fax:815-642-0356
Practice Address - Street 1:585 UNION AVE, #7A
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246
Practice Address - Country:US
Practice Address - Phone:603-387-1523
Practice Address - Fax:815-642-0356
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH137106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist