Provider Demographics
NPI:1851971873
Name:GOODWIN, JORDAN GAGE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:GAGE
Last Name:GOODWIN
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 1276
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-6276
Mailing Address - Country:US
Mailing Address - Phone:304-842-0044
Mailing Address - Fax:304-842-0033
Practice Address - Street 1:387 HELIPORT LOOP
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-8604
Practice Address - Country:US
Practice Address - Phone:304-842-0044
Practice Address - Fax:304-842-0033
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist