Provider Demographics
NPI:1407639552
Name:GOODWIN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GOODWIN
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 1:4347 E VAUGHN DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5550
Mailing Address - Country:US
Mailing Address - Phone:480-514-8991
Mailing Address - Fax:
Practice Address - Street 1:4347 E VAUGHN DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-5550
Practice Address - Country:US
Practice Address - Phone:480-514-8991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care