Provider Demographics
NPI:1225630080
Name:GOODMAN, JESSICA SMITH (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:SMITH
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S SALISBURY GQ AVE
Practice Address - Street 2:
Practice Address - City:GRANITE QUARRY
Practice Address - State:NC
Practice Address - Zip Code:28146-8150
Practice Address - Country:US
Practice Address - Phone:704-279-1679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF06201620363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner