Provider Demographics
NPI:1891235461
Name:GOODMAN, JENNIFER MICHELLE (RD)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BLYTHE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5866
Mailing Address - Country:US
Mailing Address - Phone:704-381-8388
Mailing Address - Fax:
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86058389133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered