Provider Demographics
NPI:1043716459
Name:GOLDBERG, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11012 N DALE MABRY HWY STE 304
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11012 N DALE MABRY HWY STE 304
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-3821
Practice Address - Country:US
Practice Address - Phone:813-563-7600
Practice Address - Fax:813-563-7601
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13953111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty