Provider Demographics
NPI:1598751596
Name:GOODWINE, JODY A (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:GOODWINE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 W 11TH STREET RD
Mailing Address - Street 2:SUITE #23
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5464
Mailing Address - Country:US
Mailing Address - Phone:970-351-6900
Mailing Address - Fax:970-351-7165
Practice Address - Street 1:2619 W 11TH STREET RD
Practice Address - Street 2:SUITE #23
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-5464
Practice Address - Country:US
Practice Address - Phone:970-351-6900
Practice Address - Fax:970-351-7165
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO2052101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional