| Doctor Name: | JODIE BERGQUIST |
| NPI Number: | 1144679697 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA, LPC, LCDC |
| License Number: | 12785 |
| Business Practice Address: | 30111 Canton Farms Court Brookshire, TX - 77423 |
| Business Phone Number: | 8327812153 |
| Business Fax Number: | |
| Mailing Address: | 30111 Canton Farms Court, BROOKSHIRE |
| State: | TX |
| Postal Code: | 77423 |
| Phone Number: | 8327812153 |
| Fax Number: | |
| NPI Enumeration Date: | 06/06/2016 |
| NPI Last Update Date: | 06/06/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 12785 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | TX |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |