Provider Demographics
NPI:1023762432
Name:GOODSON, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GOODSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 238TH AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18037 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2253
Practice Address - Country:US
Practice Address - Phone:708-400-9409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst