Healthcare Provider Details

I. General information

NPI: 1407907082
Provider Name (Legal Business Name): JACKY EILEEN MERGNER OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKY EILEEN BERG OTRL

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 43RD AVE N
FARGO ND
58102-5320
US

IV. Provider business mailing address

402 MAPLE ST.
HAWLEY MN
56549
US

V. Phone/Fax

Practice location:
  • Phone: 701-793-3646
  • Fax: 701-293-6892
Mailing address:
  • Phone: 218-486-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number816
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number102599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: