Provider Demographics
NPI:1245569755
Name:GOLDMAN, JENNIFER JILL (AUD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JILL
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 GRAHAM AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2996
Mailing Address - Country:US
Mailing Address - Phone:252-492-6017
Mailing Address - Fax:
Practice Address - Street 1:9380 FORESTWOOD LN STE F
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4735
Practice Address - Country:US
Practice Address - Phone:703-330-3277
Practice Address - Fax:703-368-7257
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001397231H00000X
NC12632231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist