Provider Demographics
NPI:1679044994
Name:GOODMAN, JAY RICHARD III (SLP/CF)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:RICHARD
Last Name:GOODMAN
Suffix:III
Gender:M
Credentials:SLP/CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 W WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4554
Practice Address - Country:US
Practice Address - Phone:352-357-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-14
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist