Healthcare Provider Details

I. General information

NPI: 1760794010
Provider Name (Legal Business Name): JESSICA ROSE POGRAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 2ND AVE
LONG BRANCH NJ
07740-6303
US

IV. Provider business mailing address

300 2ND AVE
LONG BRANCH NJ
07740-6303
US

V. Phone/Fax

Practice location:
  • Phone: 800-300-0628
  • Fax: 732-923-5277
Mailing address:
  • Phone: 800-300-0628
  • Fax: 732-923-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25MB099130600
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: