Individual
JEFFREY ROBERT BERGSTROM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MSW LCSW MPA
Contact information
Practice address
379 2ND STREET, MULLAN, ID 83846
(307) 264-0114
Mailing address
PO BOX 444, MULLAN, ID 83846-0444
(208) 446-6758
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
100963
CA
1041C0700X
Clinical Social Worker
Primary
40757
ID
1041C0700X
Clinical Social Worker
4686
HI
1041C0700X
Clinical Social Worker
49993
MT
Other
Enumeration date
08/08/2018
Last updated
12/27/2024
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