=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487881272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELYN ROSALYN BERGER PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2009
-----------------------------------------------------
Last Update Date | 06/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2180 PARK AVE N SUITE 300
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-647-0307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2180 PARK AVE N SUITE 300
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-647-0307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MT105
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------