Provider Demographics
NPI:1114674223
Name:GOLDSTEIN, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:GOLDSTEIN
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 1:1133 SOUTH BLVD APT 613
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3279
Mailing Address - Country:US
Mailing Address - Phone:561-322-5757
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:561-322-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program