Provider Demographics
NPI:1588984496
Name:BERNGEN, JIM W (BA/PSRS)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:W
Last Name:BERNGEN
Suffix:
Gender:M
Credentials:BA/PSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 GEORGIA PL
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2004
Mailing Address - Country:US
Mailing Address - Phone:918-658-3909
Mailing Address - Fax:
Practice Address - Street 1:208 GEORGIA PL
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2004
Practice Address - Country:US
Practice Address - Phone:918-658-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation