Provider Demographics
NPI:1699088609
Name:GOODALL, JAMIE L (LVN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:GOODALL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:L
Other - Last Name:IERONIMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4681 E WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-1642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3133 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1425
Practice Address - Country:US
Practice Address - Phone:559-453-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247414164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse