Provider Demographics
NPI:1790381408
Name:GOODALE, JESSICA L
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:GOODALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 164
Mailing Address - Street 2:
Mailing Address - City:BEACH
Mailing Address - State:ND
Mailing Address - Zip Code:58621-0164
Mailing Address - Country:US
Mailing Address - Phone:406-855-3615
Mailing Address - Fax:
Practice Address - Street 1:464 CENTRAL AVE S
Practice Address - Street 2:
Practice Address - City:BEACH
Practice Address - State:ND
Practice Address - Zip Code:58621
Practice Address - Country:US
Practice Address - Phone:406-855-3615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14810803747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant