Provider Demographics
NPI:1396721650
Name:GOETTE, JENNIFER REBECCA (OD)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:REBECCA
Last Name:GOETTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:REBECCA
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:350 RACETRACK RD NW STE C
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1554
Mailing Address - Country:US
Mailing Address - Phone:850-244-1828
Mailing Address - Fax:
Practice Address - Street 1:350 RACETRACK RD NW STE C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1554
Practice Address - Country:US
Practice Address - Phone:850-244-1828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2814152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U49741Medicare UPIN