Healthcare Provider Details

I. General information

NPI: 1699460642
Provider Name (Legal Business Name): JACOB ANDREW BERGGREN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE ANDREW BERGGREN

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W 22ND ST
SIOUX FALLS SD
57105-1554
US

IV. Provider business mailing address

18807 CHANDLER ST
OMAHA NE
68136-1224
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-5737
  • Fax:
Mailing address:
  • Phone: 402-639-7325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: