Provider Demographics
NPI:1326265372
Name:GOODMAN, JERROLD WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:WILLIAM
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2445
Mailing Address - Country:US
Mailing Address - Phone:860-561-6178
Mailing Address - Fax:860-561-6184
Practice Address - Street 1:68 S MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2445
Practice Address - Country:US
Practice Address - Phone:860-561-6178
Practice Address - Fax:860-561-6184
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000414103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical