Healthcare Provider Details

I. General information

NPI: 1134771652
Provider Name (Legal Business Name): JESSIE ALAN BERG RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 GENERAL BOOTH BLVD STE B
VIRGINIA BEACH VA
23454-5910
US

IV. Provider business mailing address

1200 KEMPSVILLE RD
NORFOLK VA
23502-2617
US

V. Phone/Fax

Practice location:
  • Phone: 757-301-2411
  • Fax:
Mailing address:
  • Phone: 757-403-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-91373
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: