Provider Demographics
NPI:1124384102
Name:GODWIN, JERMAINE LEYCESTER
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:LEYCESTER
Last Name:GODWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17406 PRONDALL CT
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1642
Mailing Address - Country:US
Mailing Address - Phone:424-222-1326
Mailing Address - Fax:
Practice Address - Street 1:17406 PRONDALL CT
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1642
Practice Address - Country:US
Practice Address - Phone:424-222-1326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator