Provider Demographics
NPI:1689360737
Name:GOFORTH, JACOB KEATON
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:KEATON
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 SUNSET CT STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-2429
Mailing Address - Country:US
Mailing Address - Phone:803-739-3550
Mailing Address - Fax:803-739-3546
Practice Address - Street 1:145 SUNSET CT STE 100
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-2429
Practice Address - Country:US
Practice Address - Phone:803-739-3550
Practice Address - Fax:803-739-3546
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program