Provider Demographics
NPI:1235149774
Name:GOLDBERG, JENNIFER (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:51 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3439
Mailing Address - Country:US
Mailing Address - Phone:973-509-6900
Mailing Address - Fax:
Practice Address - Street 1:51 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3439
Practice Address - Country:US
Practice Address - Phone:973-509-6900
Practice Address - Fax:973-509-6939
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00030300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ048271Medicare PIN
S68131Medicare UPIN