Provider Demographics
NPI:1881619526
Name:GOLDBERG, JENNIFER Y (RD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Y
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:Y
Other - Last Name:RUTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5463
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:205 S WABASHA ST
Practice Address - Street 2:MAIL STOP 31300A
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1805
Practice Address - Country:US
Practice Address - Phone:651-293-8100
Practice Address - Fax:651-293-8106
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2058133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered