Provider Demographics
NPI:1427281948
Name:GOLDBERG, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5882 HOLLYHOCK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 WILSON AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3825
Practice Address - Country:US
Practice Address - Phone:650-630-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist