Provider Demographics
NPI:1801935689
Name:GOLDBERG, JILL SUSAN (DC)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:SUSAN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 PONTIUS AVE N
Mailing Address - Street 2:SUITE 124
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-5547
Mailing Address - Country:US
Mailing Address - Phone:206-405-3333
Mailing Address - Fax:
Practice Address - Street 1:535 PONTIUS AVE N
Practice Address - Street 2:SUITE 124
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-5547
Practice Address - Country:US
Practice Address - Phone:206-405-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2013111N00000X
MD01700111N00000X
WACH00033732111N00000X
NY011513-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U75114Medicare UPIN
Y45244Medicare ID - Type Unspecified