Healthcare Provider Details

I. General information

NPI: 1871564807
Provider Name (Legal Business Name): JENNETTE SEPULVADO BERGSTEDT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 W LAFAYETTE ST
WINNFIELD LA
71483-3463
US

IV. Provider business mailing address

431 W LAFAYETTE ST
WINNFIELD LA
71483-3463
US

V. Phone/Fax

Practice location:
  • Phone: 318-648-0375
  • Fax: 318-648-0378
Mailing address:
  • Phone: 318-648-0375
  • Fax: 318-648-0378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number021307
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: