Provider Demographics
NPI:1407148711
Name:GOLDBERG, JESSICA DAWN (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:DAWN
Other - Last Name:BLUMENTHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 E 94TH ST
Mailing Address - Street 2:APARTMENT 1216
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3903
Mailing Address - Country:US
Mailing Address - Phone:917-400-6216
Mailing Address - Fax:
Practice Address - Street 1:200 E 94TH ST
Practice Address - Street 2:APARTMENT 1216
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3903
Practice Address - Country:US
Practice Address - Phone:917-400-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020798235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist