Provider Demographics
NPI:1447345608
Name:WOLLACK, JAN B (MD, PHD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:B
Last Name:WOLLACK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:CHILD NEUROLOGY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-653-9669
Mailing Address - Fax:603-653-9669
Practice Address - Street 1:19 DAVIS AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4488
Practice Address - Country:US
Practice Address - Phone:732-776-4551
Practice Address - Fax:732-776-4392
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0704752084N0402X
NH172882084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8155003Medicaid
NJ036778C6WMedicare PIN
H13056Medicare UPIN