Provider Demographics
NPI:1427778414
Name:GOODMAN, JONTAY
Entity type:Individual
Prefix:
First Name:JONTAY
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JONTAY
Other - Middle Name:
Other - Last Name:GOODMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:714 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7141
Mailing Address - Country:US
Mailing Address - Phone:843-573-3333
Mailing Address - Fax:
Practice Address - Street 1:714 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7141
Practice Address - Country:US
Practice Address - Phone:843-573-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor