Provider Demographics
NPI:1558824136
Name:GOODWIN, JEANINE MARIE (QMHP)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:MARIE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 LINCOLN ST APT 101
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3772
Mailing Address - Country:US
Mailing Address - Phone:503-381-5577
Mailing Address - Fax:
Practice Address - Street 1:110 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4307
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist