Provider Demographics
NPI:1700847399
Name:GOODRICH, JACOB ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ALLAN
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9481
Mailing Address - Country:US
Mailing Address - Phone:706-210-7529
Mailing Address - Fax:706-312-7609
Practice Address - Street 1:1706 MAGNOLIA WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9481
Practice Address - Country:US
Practice Address - Phone:706-210-7529
Practice Address - Fax:706-312-7609
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34112207X00000X, 207XS0117X
GA020540207X00000X, 207XS0117X
SC34412207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAREF000028280Medicaid
GA000239357FMedicaid
SCG20540Medicaid
SCG20540Medicaid
GA000239357FMedicaid
SCAA81889198Medicare PIN