Provider Demographics
NPI:1639399728
Name:GOODMAN, JESSICA M (PT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:CHRUSCIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1708 E SIERRA VISTA
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016
Mailing Address - Country:US
Mailing Address - Phone:602-354-7323
Mailing Address - Fax:
Practice Address - Street 1:4045 N 7TH ST
Practice Address - Street 2:SUITE 220
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014
Practice Address - Country:US
Practice Address - Phone:602-443-1030
Practice Address - Fax:602-443-1033
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ789315Medicaid