Provider Demographics
NPI:1568005049
Name:GONGOLA, JEREMY (DC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GONGOLA
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 1:31 VERVALEN ST
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2699
Mailing Address - Country:US
Mailing Address - Phone:201-784-2700
Mailing Address - Fax:
Practice Address - Street 1:31 VER VALEN ST
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-2699
Practice Address - Country:US
Practice Address - Phone:201-784-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00765000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor