Provider Demographics
NPI:1699460642
Name:BERGGREN, JACOB ANDREW (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:BERGGREN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:ANDREW
Other - Last Name:BERGGREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18807 CHANDLER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-1224
Mailing Address - Country:US
Mailing Address - Phone:402-639-7325
Mailing Address - Fax:
Practice Address - Street 1:1400 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1554
Practice Address - Country:US
Practice Address - Phone:605-322-5737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program