Provider Demographics
NPI:1891763371
Name:GOODROW, JARED JAMES (NAVY IDC)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:JAMES
Last Name:GOODROW
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2962 WELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5740
Mailing Address - Country:US
Mailing Address - Phone:619-200-3308
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE
Practice Address - Street 2:NAVAL SCHOOL OF HEALTH SCIENCES
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5291
Practice Address - Country:US
Practice Address - Phone:619-532-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman