=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154220705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA LYNN BERG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2026
-----------------------------------------------------
Last Update Date | 11/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 DURANGO DR
-----------------------------------------------------
City | GILBERTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60136-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-894-0787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 DURANGO DR
-----------------------------------------------------
City | GILBERTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60136-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-894-0787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------