Provider Demographics
NPI:1588955686
Name:BERGEN, JAIMIE MARIE (BCBA)
Entity type:Individual
Prefix:MRS
First Name:JAIMIE
Middle Name:MARIE
Last Name:BERGEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7109 DANNY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-5320
Mailing Address - Country:US
Mailing Address - Phone:209-957-7777
Mailing Address - Fax:209-473-3344
Practice Address - Street 1:7109 DANNY DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-5320
Practice Address - Country:US
Practice Address - Phone:209-957-7777
Practice Address - Fax:209-473-3344
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-12-12364103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst