Provider Demographics
NPI:1275923245
Name:GOODELL, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:GOODELL
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 1:67 SHAKER RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-9640
Mailing Address - Country:US
Mailing Address - Phone:207-657-7700
Mailing Address - Fax:
Practice Address - Street 1:67 SHAKER RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:ME
Practice Address - Zip Code:04039-9640
Practice Address - Country:US
Practice Address - Phone:207-657-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC15203103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst