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General NPI Number Information
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NPI Number | 1982303103
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Entity Type | Individual
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Provider Name | JACQUELINE LYNN BERGQUIST
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Gender | Female
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Dates
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Enumeration Date | 02/27/2023
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Last Update Date | 02/27/2023
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Provider Practice Location Address
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Address Line | 4111 BRADLEY CIR NW STE 150
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City | CANTON
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State | OH
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Zip | 44718-2563
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Country | US
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Telephone | 330-546-0199
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Fax | 330-546-0186
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Provider Business Mailing Address
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Address Line | 4111 BRADLEY CIR NW STE 150
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City | CANTON
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State | OH
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Zip | 44718-2563
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Country | US
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Telephone | 330-546-0199
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Fax | 330-546-0186
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | W.2200319
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License Number State | OH
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