Provider Demographics
NPI:1962743831
Name:GOLDSTOCK, JENNIFER LEE (ANP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:GOLDSTOCK
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:MAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-BC
Mailing Address - Street 1:654 WATERVLIET SHAKER RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110
Mailing Address - Country:US
Mailing Address - Phone:518-218-4454
Mailing Address - Fax:518-380-2023
Practice Address - Street 1:654 WATERVLIET SHAKER RD
Practice Address - Street 2:SUITE 3
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-218-4454
Practice Address - Fax:518-380-2023
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306334-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health