Provider Demographics
NPI:1154609055
Name:JARDINE, DANIELLE LOUISA (MB,BS)
Entity type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:LOUISA
Last Name:JARDINE
Suffix:
Gender:F
Credentials:MB,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MILLBURN AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1935
Mailing Address - Country:US
Mailing Address - Phone:201-221-6816
Mailing Address - Fax:
Practice Address - Street 1:120 MILLBURN AVE STE 204
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1935
Practice Address - Country:US
Practice Address - Phone:973-467-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261607207R00000X
NJ25MA09192200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ337394YH4SMedicaid