Provider Demographics
NPI:1497029110
Name:GOLDBERG, JANE (JANE GOLDBERG)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:JANE GOLDBERG
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LMFT
Mailing Address - Street 1:2033 PORT BRISTOL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5414
Mailing Address - Country:US
Mailing Address - Phone:949-760-0115
Mailing Address - Fax:
Practice Address - Street 1:2033 PORT BRISTOL CIR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5414
Practice Address - Country:US
Practice Address - Phone:949-760-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAME16867106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist