Most Relevant Information
Provider Data
| NPI Number: | 1003574971 |
| Provider Name: | JAXON BERGUM |
| Entity Type: | Individual |
| Taxonomy Code: | 247200000X |
| Specialty: | Technician, Other |
| License Number: | 10586 |
Most Important Dates
| Enumeration Date: | 12/07/2021 |
| Last Updated: | 12/07/2021 |
Provider Practice Location
930 N 3RD ST
GRAND FORKS
ND
582032408
Practice Location Phone/Fax
| Phone: | 7017959143 |
| Fax: |
Provider Mailing Location
930 N 3RD ST
GRAND FORKS
ND
582032408
Provider Mailing Phone/Fax
| Phone: | 7017959143 |
| Fax: |