Provider Demographics
NPI:1437509395
Name:GOODWINE, JENNIFER (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GOODWINE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2379 BELL CT
Mailing Address - Street 2:#76
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-1769
Mailing Address - Country:US
Mailing Address - Phone:541-261-3384
Mailing Address - Fax:
Practice Address - Street 1:345 N BARTLETT ST
Practice Address - Street 2:202
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5957
Practice Address - Country:US
Practice Address - Phone:541-261-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist