Healthcare Provider Details

I. General information

NPI: 1679983753
Provider Name (Legal Business Name): JESSICA BERGMAN M.S. SLP-CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 1ST AVE NE # 1653
BUFFALO MN
55313-1602
US

IV. Provider business mailing address

214 1ST AVE NE
BUFFALO MN
55313-1602
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-8412
  • Fax:
Mailing address:
  • Phone: 763-682-8412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8973
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: