Healthcare Provider Details

I. General information

NPI: 1740950146
Provider Name (Legal Business Name): BERGAN JAYDE JOHNSEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 RISEN SON BLVD
COUNCIL BLUFFS IA
51503-1911
US

IV. Provider business mailing address

2396 SHARON AVE
LOGAN IA
51546-5028
US

V. Phone/Fax

Practice location:
  • Phone: 712-366-9655
  • Fax:
Mailing address:
  • Phone: 712-592-3358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number110375
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: