MEDICARE: JESSICA DAWN GOLDBERG M.A. CCC SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	020798	NY

General Provider Information

NPI Number	:	1407148711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA DAWN GOLDBERG M.A. CCC SLP

Provider Business Mailing Address
First Line	:	200 E 94TH ST
Second Line	:	APARTMENT 1216
City	:	NEW YORK
State	:	NY
Zip	:	10128-3903
Country	:	US
Telephone Number	:	917-400-6216
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 E 94TH ST
Second Line	:	APARTMENT 1216
City	:	NEW YORK
State	:	NY
Zip	:	10128-3903
Country	:	US
Telephone Number	:	917-400-6216
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	05/04/2011

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