Provider Demographics
NPI:1134237779
Name:GOODMAN, JAY A (PH D)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:A
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 PENNY LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6012
Mailing Address - Country:US
Mailing Address - Phone:831-728-3189
Mailing Address - Fax:831-662-0756
Practice Address - Street 1:54 PENNY LN
Practice Address - Street 2:SUITE B
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6012
Practice Address - Country:US
Practice Address - Phone:831-728-3189
Practice Address - Fax:831-662-0756
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11430103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL11430Medicare ID - Type Unspecified