Provider Demographics
NPI:1568251619
Name:GOLDBERG, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 PENNSYLVANIA ST NE APT 2104
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7532
Mailing Address - Country:US
Mailing Address - Phone:505-427-3016
Mailing Address - Fax:
Practice Address - Street 1:1401 PENNSYLVANIA ST NE APT 2104
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7532
Practice Address - Country:US
Practice Address - Phone:505-427-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician