Provider Demographics
NPI:1184425969
Name:GOODMAN, JO ANNA (PSS)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:ANNA
Last Name:GOODMAN
Suffix:
Gender:
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W MARINE DR APT 78
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-5623
Mailing Address - Country:US
Mailing Address - Phone:503-791-7086
Mailing Address - Fax:
Practice Address - Street 1:1400 W MARINE DR APT 78
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-5623
Practice Address - Country:US
Practice Address - Phone:503-791-7086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR112889106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician