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
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | MC05797 | NJ | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 201073024 | 01 | NJ | TAX ID | OTHER |