Provider Demographics
NPI:1619990652
Name:EDWARDS, JENNIFER GOODE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:GOODE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LEATRICE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 74365
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-0007
Mailing Address - Country:US
Mailing Address - Phone:804-745-3011
Mailing Address - Fax:804-745-3012
Practice Address - Street 1:9409 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23236-1200
Practice Address - Country:US
Practice Address - Phone:804-745-3011
Practice Address - Fax:804-745-3012
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300803213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9303502Medicaid
VA9303502Medicaid
VAU83824Medicare UPIN