Provider Demographics
NPI:1730763186
Name:BERGERON, JACOBY DALE (DC)
Entity type:Individual
Prefix:DR
First Name:JACOBY
Middle Name:DALE
Last Name:BERGERON
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 1:4030 W BRAKER LN
Mailing Address - Street 2:BLDG 4 SUITE 405
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3609
Mailing Address - Country:US
Mailing Address - Phone:218-688-1454
Mailing Address - Fax:
Practice Address - Street 1:4030 W BRAKER LN
Practice Address - Street 2:BLDG 4 SUITE 405
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3609
Practice Address - Country:US
Practice Address - Phone:218-688-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty