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General NPI Number Information
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NPI Number | 1538448766
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Entity Type | Individual
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Provider Name | JACOB P BERGSTEDT IMFT, LMFT
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Gender | Male
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Dates
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Enumeration Date | 08/05/2011
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 801 TWELVE OAKS CENTER DR STE 812
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City | WAYZATA
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State | MN
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Zip | 55391-4625
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Country | US
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Telephone | 952-956-2027
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Fax | 952-900-8132
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Provider Business Mailing Address
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Address Line | 801 TWELVE OAKS CENTER DR STE 812
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City | WAYZATA
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State | MN
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Zip | 55391-4625
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Country | US
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Telephone | 952-956-2027
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Fax | 952-900-8132
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | F-1500003
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 2331
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License Number State | MN
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