Basic Information
| Provider Information | |||||||||
| NPI: | 1285950220 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDMAN | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910302630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234041027 | ||||||||
| FaxNumber: | 3233408298 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 W 6TH ST | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234041027 | ||||||||
| FaxNumber: | 3233408298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2010 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 11171 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.