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1093615809 NPI number — JEDD BEROS

NPI Number: 1093615809
Health Care Provider/Practitioner: JEDD BEROS

Information about “1093615809” NPI (JEDD BEROS) exists in 1093615809 in HTML format HTML  |  1093615809 in plain Text format TXT  |  1093615809 in PDF (Portable Document Format) PDF  |  1093615809 in an XML format XML  formats.

NPI Number : 1093615809 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1093615809",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "BEROS",
    "FirstName": "JEDD",
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "3100 CHANNEL DR STE 300",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "JUNEAU",
    "MailingAddressStateName": "AK",
    "MailingAddressPostalCode": "99801-7837",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "3051 VINTAGE BOULEVARD",
    "SecondLinePracticeLocationAddress": "3RD FLOOR- PHYSICAL REHABILITATION",
    "PracticeLocationAddressCityName": "JUNEAU",
    "PracticeLocationAddressStateName": "AK",
    "PracticeLocationAddressPostalCode": "99801",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "907-463-0140",
    "PracticeLocationAddressFaxNumber": "907-463-0141",
    "EnumerationDate": "11/06/2026",
    "LastUpdateDate": "11/06/2026",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "225400000X",
        "TaxonomyName": "Rehabilitation Practitioner",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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