Healthcare Provider Details

I. General information

NPI: 1811809379
Provider Name (Legal Business Name): JACOB CHESTER BERGELIN PARAMEDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E EMERSON ST
BLOOMINGTON IL
61701-1913
US

IV. Provider business mailing address

1101 E EMERSON ST
BLOOMINGTON IL
61701-1913
US

V. Phone/Fax

Practice location:
  • Phone: 309-826-9365
  • Fax:
Mailing address:
  • Phone: 309-826-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number060829595
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: