Provider Demographics
NPI:1710297726
Name:GOLDMAN, JILLIAN
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:GOLDMAN
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 1:1156 N BROADWAY
Mailing Address - Street 2:ANDRUS CHILDREN'S CENTER
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1108
Mailing Address - Country:US
Mailing Address - Phone:914-965-3700
Mailing Address - Fax:
Practice Address - Street 1:1156 N BROADWAY
Practice Address - Street 2:ANDRUS CHILDREN'S CENTER
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1108
Practice Address - Country:US
Practice Address - Phone:914-965-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-12
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00745088OtherAGENCY'S MEDICAID MMIS #
NY1003991019OtherAGENCY'S NPI #