Provider Demographics
NPI:1538724455
Name:BERG, JACOB TYRELL (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:TYRELL
Last Name:BERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 S SUNNYCREST RD
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98178-2749
Mailing Address - Country:US
Mailing Address - Phone:307-630-9380
Mailing Address - Fax:
Practice Address - Street 1:205 SMALLBERRY CT
Practice Address - Street 2:
Practice Address - City:SNEADS FERRY
Practice Address - State:NC
Practice Address - Zip Code:28460-6827
Practice Address - Country:US
Practice Address - Phone:307-630-9380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20890207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine