Healthcare Provider Details

I. General information

NPI: 1376748103
Provider Name (Legal Business Name): UMDNJ RWJ OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ROBERT WOOD JOHNSON PL HIGH RISK CLINIC ATRIUM
NEW BRUNSWICK NJ
08901-1928
US

IV. Provider business mailing address

125 PATERSON ST STE. 2142
NEW BRUNSWICK NJ
08901-1962
US

V. Phone/Fax

Practice location:
  • Phone: 732-253-3892
  • Fax:
Mailing address:
  • Phone: 732-253-3892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP1700X
TaxonomyPerinatal Nurse Practitioner
License NumberNR05721700
License Number StateNJ

VIII. Authorized Official

Name: MS. CHRISTINE L JACKSON
Title or Position: PROGRAM ASSISTANT
Credential:
Phone: 732-235-5335