Basic Information
| Provider Information | |||||||||
| NPI: | 1427611102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGLASS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | BLANCHE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1424 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011720 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1424 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257892000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2019 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OP61315834 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.