Healthcare Provider Details

I. General information

NPI: 1922374818
Provider Name (Legal Business Name): JASON THOMAS BERG MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 FORREST AVE STE 101
DOVER DE
19904-3483
US

IV. Provider business mailing address

350 NEW FIDELITY CT
GARNER NC
27529-2665
US

V. Phone/Fax

Practice location:
  • Phone: 302-735-4900
  • Fax: 302-735-4900
Mailing address:
  • Phone: 919-258-2714
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0014240
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 27059
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: