Provider Demographics
NPI:1568279032
Name:BERG, JACKIE M
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
Last Name:BERG
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:FORBESTOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95941-0037
Mailing Address - Country:US
Mailing Address - Phone:530-675-2577
Mailing Address - Fax:
Practice Address - Street 1:18997 NEW YORK FLAT RD.
Practice Address - Street 2:
Practice Address - City:FORBESTOWN
Practice Address - State:CA
Practice Address - Zip Code:95941-0037
Practice Address - Country:US
Practice Address - Phone:530-675-2577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver