Provider Demographics
NPI:1003810664
Name:GOODIN, JACQUELINE H (LISW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:H
Last Name:GOODIN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 MARLOWE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4318
Mailing Address - Country:US
Mailing Address - Phone:216-226-6851
Mailing Address - Fax:
Practice Address - Street 1:3430 ROCKY RIVER DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-2954
Practice Address - Country:US
Practice Address - Phone:216-688-1111
Practice Address - Fax:216-251-2886
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI54541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGOSW19801Medicare ID - Type Unspecified