Provider Demographics
NPI:1487824165
Name:GOODRUM, JIM
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:GOODRUM
Suffix:
Gender:M
Credentials:
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 3546
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-3546
Mailing Address - Country:US
Mailing Address - Phone:909-866-5437
Mailing Address - Fax:909-866-8555
Practice Address - Street 1:40880 PEDDER RD
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-5437
Practice Address - Fax:909-866-8555
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)