Provider Demographics
NPI:1124137765
Name:GOFFMAN, JERRY M (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:GOFFMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 S MOUNT VERNON AVE
Mailing Address - Street 2:G-306
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4228
Mailing Address - Country:US
Mailing Address - Phone:951-312-1041
Mailing Address - Fax:
Practice Address - Street 1:8253 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:951-312-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7081103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY070812Medicaid
CAPSY070811Medicaid
CAPSY070812Medicaid
CAPSY070811Medicaid