Provider Demographics
NPI:1205878105
Name:GOODFRED, JENNIFER CELESTE (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CELESTE
Last Name:GOODFRED
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9398 DOGWOOD RD S
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-5737
Mailing Address - Country:US
Mailing Address - Phone:901-378-4705
Mailing Address - Fax:
Practice Address - Street 1:8970 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8231
Practice Address - Country:US
Practice Address - Phone:901-794-5806
Practice Address - Fax:901-794-7922
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24106207Q00000X
TN1711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181844AMedicaid
MS01203728Medicaid
TN3319805Medicaid
KY7100484990Medicaid
MO1205878105Medicaid
AR187976003Medicaid