Provider Demographics
NPI:1487198651
Name:GOODMAN, JESSICA V
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:V
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 BONITA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1014
Mailing Address - Country:US
Mailing Address - Phone:707-435-3764
Mailing Address - Fax:
Practice Address - Street 1:1918 BONITA AVE STE 200
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1014
Practice Address - Country:US
Practice Address - Phone:707-435-3764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69425101YM0800X
CA1013611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health