Provider Demographics
NPI:1518081041
Name:GOODMAN, JERRI (MFT)
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 SANTA CARLOTTA ST
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1053
Mailing Address - Country:US
Mailing Address - Phone:818-541-5500
Mailing Address - Fax:818-541-5500
Practice Address - Street 1:3941 SANTA CARLOTTA ST
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1053
Practice Address - Country:US
Practice Address - Phone:818-541-5500
Practice Address - Fax:818-541-5500
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29048106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist