Basic Information
Provider Information
NPI: 1003013897
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DINNERMAN
FirstName: JODI
MiddleName: NICHOLE
NamePrefix: DR.
NameSuffix:  
Credential: DC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: CHIROPRACTIC
OtherFirstName: LIGHTSOURCE
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 5
Mailing Information
Address1: 23 NORTHWOOD DR
Address2:  
City: PITTSTOWN
State: NJ
PostalCode: 088675129
CountryCode: US
TelephoneNumber: 9087359355
FaxNumber:  
Practice Location
Address1: 16 LEIGH ST
Address2: STE 1C
City: CLINTON
State: NJ
PostalCode: 088091412
CountryCode: US
TelephoneNumber: 9082381081
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/27/2007
LastUpdateDate: 01/03/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000XMC05797NJY Chiropractic ProvidersChiropractor 

ID Information
IDTypeStateIssuerDescription
22378820701 TAX ID NUMBEROTHER
20107302401NJTAX IDOTHER


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