Healthcare Provider Details

I. General information

NPI: 1962552638
Provider Name (Legal Business Name): JESSE R. LIEBMAN DC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OLD MARLTON PIKE W
MARLTON NJ
08053-2026
US

IV. Provider business mailing address

100 OLD MARLTON PIKE W
MARLTON NJ
08053-2026
US

V. Phone/Fax

Practice location:
  • Phone: 856-596-3000
  • Fax: 856-596-3301
Mailing address:
  • Phone: 856-596-3000
  • Fax: 856-596-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number38MC00423400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: