Basic Information
| Provider Information | |||||||||
| NPI: | 1639313208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGERON | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | BEAGHAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | DEPT 351 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015162362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1169 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381047217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014251880 | ||||||||
| FaxNumber: | 9017255766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 50407 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 50407 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q013161 | 05 | TN | MEDICAID | 6055871 | 01 | TN | BCBS | OTHER | 04058365 | 05 | MS | MEDICAID | 199952001 | 05 | AR | MEDICAID |