Provider Demographics
NPI:1528537552
Name:GOODWIN, JENNIE (NP)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWSHAW CAMPGROUND LN
Mailing Address - Street 2:
Mailing Address - City:NEWLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28657-7410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 HOSPITAL DR
Practice Address - Street 2:UNIT 230
Practice Address - City:LINVILLE
Practice Address - State:NC
Practice Address - Zip Code:28646
Practice Address - Country:US
Practice Address - Phone:828-737-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011212363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily