Provider Demographics
NPI:1891271706
Name:BERGEN, JACOB ALOYSIUS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALOYSIUS
Last Name:BERGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N PACIFIC COAST HWY STE 1400
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6223 N CANTON CENTER RD STE 210
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2696
Practice Address - Country:US
Practice Address - Phone:734-203-7675
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-23-66254103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst