Provider Demographics
NPI:1063647782
Name:JENNIFER MCGOLDRICK LLC
Entity Type:Organization
Organization Name:JENNIFER MCGOLDRICK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE-MCGOLDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, BCBA-D
Authorized Official - Phone:813-382-1459
Mailing Address - Street 1:10526 PALM COVE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2987
Mailing Address - Country:US
Mailing Address - Phone:813-994-5890
Mailing Address - Fax:
Practice Address - Street 1:10526 PALM COVE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2987
Practice Address - Country:US
Practice Address - Phone:813-994-5890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-01-0483103K00000X
FLPY7716103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty