{
"Npi": {
"NPI": "1386277507",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "BERGSTROM",
"FirstName": "JENNIFER",
"MiddleName": "WILLIAMS",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "DDS, MD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6121 N BAY RIDGE AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WHITEFISH BAY",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53217-4326",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "916-475-4401",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "5000 W NATIONAL AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MILWAUKEE",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "53295-3098",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "414-384-2000",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/17/2020",
"LastUpdateDate": "08/03/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "D10925",
"LicenseNumberStateCode": "OR",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "204E00000X",
"TaxonomyName": "Oral & Maxillofacial Surgery (D.M.D.)",
"LicenseNumber": "8426620",
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": "600175115",
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}