Provider Demographics
NPI:1164910626
Name:GOODE, JEMAMIA JAMIE
Entity Type:Individual
Prefix:
First Name:JEMAMIA
Middle Name:JAMIE
Last Name:GOODE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3469 SOUTHRIDGE PL APT 10
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7911
Mailing Address - Country:US
Mailing Address - Phone:580-678-7260
Mailing Address - Fax:
Practice Address - Street 1:1373 E BOONE ST STE 2300
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3365
Practice Address - Country:US
Practice Address - Phone:918-207-0025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK6659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program