Provider Demographics
NPI:1285090407
Name:DULBERG, JENIFER
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:DULBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 STEVEN PL
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-4500
Mailing Address - Country:US
Mailing Address - Phone:561-306-8417
Mailing Address - Fax:
Practice Address - Street 1:14 STEVEN PL
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727
Practice Address - Country:US
Practice Address - Phone:561-306-8417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor