Provider Demographics
NPI:1912243569
Name:GOODWIN, JESSIE KEIKO (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:KEIKO
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:11276 5TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0921
Practice Address - Country:US
Practice Address - Phone:909-481-0437
Practice Address - Fax:909-481-0837
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist