Provider Demographics
NPI:1003013897
Name:DINNERMAN, JODI NICHOLE (DC)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:NICHOLE
Last Name:DINNERMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LIGHTSOURCE
Other - Middle Name:
Other - Last Name:CHIROPRACTIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23 NORTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PITTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08867-5129
Mailing Address - Country:US
Mailing Address - Phone:908-735-9355
Mailing Address - Fax:
Practice Address - Street 1:16 LEIGH ST
Practice Address - Street 2:STE 1C
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809-1412
Practice Address - Country:US
Practice Address - Phone:908-238-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC05797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ201073024OtherTAX ID
NJ201073024OtherTAX ID