Provider Demographics
NPI:1831327006
Name:GOODRUM, KEVON JABARR
Entity type:Individual
Prefix:MR
First Name:KEVON
Middle Name:JABARR
Last Name:GOODRUM
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:K.
Other - Middle Name:JABARR
Other - Last Name:GOODRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1812 HIDDEN SPRINGS WALK SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-4254
Mailing Address - Country:US
Mailing Address - Phone:678-444-4505
Mailing Address - Fax:
Practice Address - Street 1:46 RIDGE RD
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-3506
Practice Address - Country:US
Practice Address - Phone:203-752-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001607106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042699Medicaid
CT500000315Medicaid
CT004082286Medicaid
CT008042699Medicaid