Basic Information
| Provider Information | |||||||||
| NPI: | 1538589163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGLUND | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | APRN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | ESSENTIA HEALTH SOUTH UNIVERSITY CLINIC | ||||||||
| Address2: | 1702 UNIVERSITY DRIVE SOUTH | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2014 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R170169-6 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | R44483 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.