Active NPI
Jaxon Bergum
- Other Technician
- Grand Forks, ND
National Provider Identifier
1003574971
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Other Technician
- License
- 10586
- Practice address
- 930 N 3Rd St
Grand Forks, ND 58203-2408 - Phone
- (701) 795-9143
- NPI assigned
- Dec 7, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Other Technician | 247200000X | 10586 | Primary |
Addresses
Primary practice location
930 N 3Rd St
Grand Forks, ND 58203-2408
Mailing address
930 N 3Rd St
Grand Forks, ND 58203-2408
Phone (701) 795-9143
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Prairie Harvest Mental Health | Current | Accepting new patients |
Locations
930 N 3rd St
Grand Forks, ND 58203
Phone (701) 795-9143
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Community/Behavioral Health Agency
- Grand Forks, ND
- NPI 1447865100
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1638835200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1638835200000",
"number": "1003574971",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "930 N 3RD ST",
"city": "GRAND FORKS",
"state": "ND",
"postal_code": "582032408",
"telephone_number": "701-795-9143"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "930 N 3RD ST",
"city": "GRAND FORKS",
"state": "ND",
"postal_code": "582032408",
"telephone_number": "701-795-9143"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BERGUM",
"first_name": "JAXON",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-12-07",
"last_updated": "2021-12-07",
"certification_date": "2021-12-07",
"status": "A"
},
"taxonomies": [
{
"code": "247200000X",
"taxonomy_group": "",
"desc": "Technician, Other",
"state": null,
"license": "10586",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Grand Forks, ND
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 7, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.