Provider Demographics
NPI:1467779942
Name:GOLDENBERG, JERRY SIMON (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:SIMON
Last Name:GOLDENBERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4311
Mailing Address - Country:US
Mailing Address - Phone:718-757-0199
Mailing Address - Fax:
Practice Address - Street 1:282 HOBART ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-4311
Practice Address - Country:US
Practice Address - Phone:718-757-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00682600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor