Basic Information
| Provider Information | |||||||||
| NPI: | 1851869689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGQUIST | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PINE | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | DANIELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1991 CAROUSEL DR | ||||||||
| Address2: | |||||||||
| City: | HOLLISTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950235660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314441760 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1485 SARATOGA AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951294965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779910009 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2018 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CA | Y |
No ID Information.