Healthcare Provider Details

I. General information

NPI: 1932163342
Provider Name (Legal Business Name): JENNIFER IBRAHIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST 2 E
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

34 E BROAD ST
BERGENFIELD NJ
07621-3004
US

V. Phone/Fax

Practice location:
  • Phone: 201-227-5526
  • Fax: 201-503-1029
Mailing address:
  • Phone: 201-387-1033
  • Fax: 201-503-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMA71003
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: