Provider Demographics
NPI:1477535979
Name:GOODMAN, JERRI (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68952
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-0952
Mailing Address - Country:US
Mailing Address - Phone:317-802-6302
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:1515 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3453
Practice Address - Country:US
Practice Address - Phone:317-802-6302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28120956367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCC9320LMedicare PIN
IN215530NMedicare PIN