Provider Demographics
NPI:1598088288
Name:GOODSPEED, JASON R
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:GOODSPEED
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 1:4 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:NY
Mailing Address - Zip Code:12834-1134
Mailing Address - Country:US
Mailing Address - Phone:518-692-0276
Mailing Address - Fax:
Practice Address - Street 1:2 N PARK ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-1105
Practice Address - Country:US
Practice Address - Phone:518-677-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist