Provider Demographics
NPI:1548969702
Name:BERGSTROM, JACK E (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 N BIRCHNELL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1003
Mailing Address - Country:US
Mailing Address - Phone:626-482-2481
Mailing Address - Fax:
Practice Address - Street 1:84 S PALM AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3101
Practice Address - Country:US
Practice Address - Phone:626-280-9968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36290111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36290OtherCALIFORNIA CHIROPRACTIC BOARD
CAF3317513OtherCALIFORNIA DRIVERS LICENSE