Provider Demographics
NPI:1972164911
Name:BERMAN, JACQUELINE (MS OT R/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BERMAN
Suffix:
Gender:F
Credentials:MS OT R/L
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:MARKOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS OT R/L
Mailing Address - Street 1:4 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-4755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 BLOOMFIELD AVE STE 102
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5105
Practice Address - Country:US
Practice Address - Phone:973-744-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00592600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist