Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003210097 |
---|---|
Provider Name | Ms. Jessica Beth Berg |
First Address | Waukegan, IL 60085-5131 |
Second Address | Waukegan, IL 60085-5131 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2014 |
Last Update Date | 20/10/2014 |