Provider Demographics
NPI:1619234556
Name:ROSENBERG, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 TREATY ELM LN
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-3413
Mailing Address - Country:US
Mailing Address - Phone:267-980-8177
Mailing Address - Fax:
Practice Address - Street 1:3000 LINCOLN DR E
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1500
Practice Address - Country:US
Practice Address - Phone:267-292-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-17
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA099863002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry