Provider Demographics
NPI:1508187212
Name:GOODMAN, JENNIFER (BS, MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:BS, MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 WARREN RD
Mailing Address - Street 2:TST BOCES
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1862
Mailing Address - Country:US
Mailing Address - Phone:607-257-2530
Mailing Address - Fax:
Practice Address - Street 1:555 WARREN RD
Practice Address - Street 2:TST BOCES
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1862
Practice Address - Country:US
Practice Address - Phone:607-257-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010631-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist