Basic Information
| Provider Information | |||||||||
| NPI: | 1043254006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGE | ||||||||
| FirstName: | JERICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | UMPHYSICIANS BROADWAY FAMILY MEDICINE | ||||||||
| Address2: | 1020 WEST BROADWAY | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
| FaxNumber: | 6123028275 | ||||||||
| Practice Location | |||||||||
| Address1: | UMPHYSICIANS BROADWAY FAMILY MEDICINE | ||||||||
| Address2: | 1020 WEST BROADWAY | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
| FaxNumber: | 6123028275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1218 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40992300 | 05 | WI | MEDICAID | 62-66860 | 01 | MN | UBH | OTHER | 1044097 | 01 | MN | PREFERRED ONE | OTHER | 136417 | 01 | MN | UCARE | OTHER | HP37859 | 01 | MN | HEALTHPARTNERS | OTHER |