MEDICARE: MR. JESSIE ALAN BERG RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-19-91373	VA

General Provider Information

NPI Number	:	1134771652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSIE ALAN BERG RBT

Provider Business Mailing Address
First Line	:	1200 KEMPSVILLE RD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-2617
Country	:	US
Telephone Number	:	757-403-0661
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 GENERAL BOOTH BLVD STE B
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5910
Country	:	US
Telephone Number	:	757-301-2411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	07/15/2019

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