Provider Demographics
NPI:1174644223
Name:GOTHAM, JENNIFER M
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:M
Last Name:GOTHAM
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 1:80 STATE HIGHWAY 310
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1493
Mailing Address - Country:US
Mailing Address - Phone:315-386-2189
Mailing Address - Fax:315-386-2435
Practice Address - Street 1:80 STATE HIGHWAY 310
Practice Address - Street 2:SUITE 1
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1493
Practice Address - Country:US
Practice Address - Phone:315-386-2189
Practice Address - Fax:315-386-2435
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)