Provider Demographics
NPI:1811341506
Name:GODWIN, JENNIE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:GODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 JOHN NOLEN DR
Mailing Address - Street 2:APT 201
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1402
Mailing Address - Country:US
Mailing Address - Phone:870-404-3510
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6461-851208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics