Provider Demographics
NPI:1588840805
Name:GOODWIN, JAKE CLINTON (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:CLINTON
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 19TH ST N
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35020-4821
Mailing Address - Country:US
Mailing Address - Phone:205-424-2020
Mailing Address - Fax:205-425-5665
Practice Address - Street 1:512 19TH ST N
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35020-4821
Practice Address - Country:US
Practice Address - Phone:205-424-2020
Practice Address - Fax:205-425-5665
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL08007709156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4403430001Medicare NSC