Provider Demographics
NPI:1154976264
Name:GOODRICH, JILLIAN (CAGS)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 MASSACHUSETTS AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:BOXBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01719-1528
Mailing Address - Country:US
Mailing Address - Phone:978-501-6813
Mailing Address - Fax:
Practice Address - Street 1:629 MASSACHUSETTS AVE STE 201
Practice Address - Street 2:
Practice Address - City:BOXBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01719-1528
Practice Address - Country:US
Practice Address - Phone:978-501-6813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA477840103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool