N.J.S.A. 45:9-22.22(b) requires all licensees to provide any information necessary to complete a health care practitioner profile.
You therefore must complete all required information fields.
Licensees who fail to provide required information, or provide knowingly false information, may be subject to disciplinary action,
to include the suspension or revocation of licensure and/or the imposition of civil penalties as may be authorized by law.
Checking the signature box will affirm that the statements made in this profile are true, complete and correct.
Enter the date. (Example: 03-24-2015) The date must be the current date.
When finished, click one of the buttons at the bottom of the screen:
Save & go to previous page
Save & stop for now
Save & go to next page