Provider Demographics
NPI:1932500683
Name:COBURGER, JACKIE (MASTER OF SOCIAL WOR)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:COBURGER
Suffix:
Gender:F
Credentials:MASTER OF SOCIAL WOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-2335
Mailing Address - Country:US
Mailing Address - Phone:732-586-9550
Mailing Address - Fax:
Practice Address - Street 1:432 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-2335
Practice Address - Country:US
Practice Address - Phone:732-586-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023701Medicaid
NJ7797403Medicaid