Provider Demographics
NPI:1588019947
Name:GOODMAN, JESSICA RYAN JACQUES (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RYAN JACQUES
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2351
Mailing Address - Country:US
Mailing Address - Phone:860-829-8939
Mailing Address - Fax:
Practice Address - Street 1:1166 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2351
Practice Address - Country:US
Practice Address - Phone:860-829-8939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004996152W00000X
CT3377152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist