Provider Demographics
NPI:1053863142
Name:GOODWIN, JACQUELINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LEE
Other - Last Name:DEGANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:150 BEACHVIEW AVE
Mailing Address - Street 2:APT 298
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-3234
Mailing Address - Country:US
Mailing Address - Phone:781-799-4213
Mailing Address - Fax:
Practice Address - Street 1:150 BEACHVIEW AVE
Practice Address - Street 2:APT 298
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-3234
Practice Address - Country:US
Practice Address - Phone:781-799-4213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4375225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist