Provider Demographics
NPI:1881568525
Name:BERG, JENNA NICOLE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-2610
Mailing Address - Country:US
Mailing Address - Phone:409-422-4994
Mailing Address - Fax:
Practice Address - Street 1:2353 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-2610
Practice Address - Country:US
Practice Address - Phone:409-422-4994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-04
Last Update Date:2025-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1028081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty