Basic Information
| Provider Information | |||||||||
| NPI: | 1316294937 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GOODMAN | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6416 TUPPER LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SUNFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488909733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172905548 | ||||||||
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| Practice Location | |||||||||
| Address1: | 303 N HURSTBOURNE PKWY | ||||||||
| Address2: | 200 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024125847 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502001974 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.