Healthcare Provider Details

I. General information

NPI: 1790860476
Provider Name (Legal Business Name): MICHAEL JARED EDENZON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 CONCORD AVENUE STE 101
WILMINGTON DE
19802-3366
US

IV. Provider business mailing address

15 BURNT MILL ROAD
CHERRY HILL NJ
08003-3947
US

V. Phone/Fax

Practice location:
  • Phone: 302-777-5551
  • Fax: 302-777-5567
Mailing address:
  • Phone: 856-422-9234
  • Fax: 856-422-9233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC-007149-L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number111NN1001X
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: