Provider Demographics
NPI:1962552638
Name:LIEBMAN, JESSE R (DC)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:R
Last Name:LIEBMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 OLD MARLTON PIKE W
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2026
Mailing Address - Country:US
Mailing Address - Phone:856-596-3000
Mailing Address - Fax:856-596-3301
Practice Address - Street 1:100 OLD MARLTON PIKE W
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2026
Practice Address - Country:US
Practice Address - Phone:856-596-3000
Practice Address - Fax:856-596-3301
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00423400111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP2705755OtherOXFORD
NJU35059Medicaid
NJ2116578000OtherAMERIHEALTH
NJ2116578000OtherKEYSTONE HEALTH PLAN EAST
NJ2116578000OtherPA.BLUE SHIELD-PERS.CH.
NJ2664713OtherAETNA
NJU35059Medicaid
NJP2705755OtherOXFORD