Provider Demographics
NPI:1619447752
Name:GOODSON, JODY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:GOODSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8833 BEECHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-8721
Mailing Address - Country:US
Mailing Address - Phone:269-357-3737
Mailing Address - Fax:
Practice Address - Street 1:4066 RED ARROW HWY STE A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9209
Practice Address - Country:US
Practice Address - Phone:269-408-0494
Practice Address - Fax:269-408-0492
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-02
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist