Healthcare Provider Details

I. General information

NPI: 1114243615
Provider Name (Legal Business Name): JONATHAN GELLER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 11/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 NASSAU ST
PRINCETON NJ
08540-4619
US

IV. Provider business mailing address

247 NASSAU ST
PRINCETON NJ
08540-4619
US

V. Phone/Fax

Practice location:
  • Phone: 609-915-4990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberNJ 4260
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: