Provider Demographics
NPI:1598419079
Name:KIRSHBAUM, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:KIRSHBAUM
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 1:140 MARKET ST FL 2
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-1471
Mailing Address - Country:US
Mailing Address - Phone:973-742-4200
Mailing Address - Fax:
Practice Address - Street 1:140 MARKET ST FL 2
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07505-1471
Practice Address - Country:US
Practice Address - Phone:973-742-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLL9081223P0221X
390200000X
NJ22DI030650001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid