Provider Demographics
NPI:1699185322
Name:BERGREN, JESSE J (LAC)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:J
Last Name:BERGREN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-3530
Mailing Address - Country:US
Mailing Address - Phone:406-399-1757
Mailing Address - Fax:
Practice Address - Street 1:332 2ND AVE
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-3530
Practice Address - Country:US
Practice Address - Phone:406-399-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3404101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)