Provider Demographics
NPI:1740611656
Name:GOLDBERG, JAMIE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:S
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, ATC
Mailing Address - Street 1:54 E NEWTOWN PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-2973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N ITHAN AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1773
Practice Address - Country:US
Practice Address - Phone:610-658-3950
Practice Address - Fax:610-520-3919
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART004959174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist