Provider Demographics
NPI:1518475573
Name:GOLDSMITH, JENNA ROSE (DC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ROSE
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 HIGHWAY 96 E STE 118
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3607
Mailing Address - Country:US
Mailing Address - Phone:651-483-0140
Mailing Address - Fax:
Practice Address - Street 1:1310 HIGHWAY 96 E STE 118
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3607
Practice Address - Country:US
Practice Address - Phone:651-483-0140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6428111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor