Provider Demographics
NPI:1346694031
Name:GOLDMAN, JEREMY ZACK (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ZACK
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 MIAMI AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-7318
Mailing Address - Country:US
Mailing Address - Phone:248-514-6757
Mailing Address - Fax:
Practice Address - Street 1:3513 MIAMI AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-7318
Practice Address - Country:US
Practice Address - Phone:248-514-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401000731103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst