Healthcare Provider Details

I. General information

NPI: 1528418993
Provider Name (Legal Business Name): JENNIFER ANN BERGMANN-KRAUSE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ELEVEN S STE 4A
COLUMBIA IL
62236-1077
US

IV. Provider business mailing address

1000 ELEVEN S STE 4A
COLUMBIA IL
62236-1077
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-6120
  • Fax: 618-206-6119
Mailing address:
  • Phone: 618-206-6120
  • Fax: 618-206-6119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209014652
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN154908, APRN PEND
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014652
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016025945
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: