Healthcare Provider Details

I. General information

NPI: 1467900951
Provider Name (Legal Business Name): JERRY ANNE BERG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 LAKE AVE
ASHTABULA OH
44004-4954
US

IV. Provider business mailing address

PO BOX 92987
CLEVELAND OH
44194-3436
US

V. Phone/Fax

Practice location:
  • Phone: 440-998-0322
  • Fax: 440-998-4525
Mailing address:
  • Phone: 440-997-2262
  • Fax: 440-997-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06161721
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: