Provider Demographics
NPI:1598102428
Name:GOODLE, JODY DENISE
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:DENISE
Last Name:GOODLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JODY
Other - Middle Name:DENISE
Other - Last Name:TIMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:N8808 HIGH RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-8503
Mailing Address - Country:US
Mailing Address - Phone:920-222-4506
Mailing Address - Fax:
Practice Address - Street 1:N8808 HIGH RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-8503
Practice Address - Country:US
Practice Address - Phone:920-222-4506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-01
Last Update Date:2013-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI316860-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse