Provider Demographics
NPI:1639827637
Name:WEINBERG, JILLIAN ROSE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ROSE
Last Name:WEINBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 MARCUS AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-2058
Mailing Address - Country:US
Mailing Address - Phone:516-358-1808
Mailing Address - Fax:
Practice Address - Street 1:1991 MARCUS AVE STE 104
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2058
Practice Address - Country:US
Practice Address - Phone:516-358-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program