Provider Demographics
NPI:1417212390
Name:GODWIN, JACQUELINE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GODWIN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W BALTIMORE PIKE STE 100B
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5639
Mailing Address - Country:US
Mailing Address - Phone:610-572-5520
Mailing Address - Fax:610-572-5521
Practice Address - Street 1:77 W BALTIMORE PIKE STE 100B
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5639
Practice Address - Country:US
Practice Address - Phone:610-572-5520
Practice Address - Fax:610-572-5521
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-07
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-10-7630103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst