Provider Demographics
NPI:1528091402
Name:GOODMAN, JEFFREY SAMUEL (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SAMUEL
Last Name:GOODMAN
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 1:355 CRAWFORD ST
Mailing Address - Street 2:SUITE 804
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2816
Mailing Address - Country:US
Mailing Address - Phone:757-397-4394
Mailing Address - Fax:757-397-3990
Practice Address - Street 1:355 CRAWFORD ST
Practice Address - Street 2:SUITE 804
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2816
Practice Address - Country:US
Practice Address - Phone:757-397-4394
Practice Address - Fax:757-397-3990
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001065103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007758201Medicaid
VA620000113Medicare ID - Type Unspecified
VAR36750Medicare UPIN