1619990652 NPI number — DR. JENNIFER GOODE EDWARDS DPM

Table of content: DR. JENNIFER GOODE EDWARDS DPM (NPI 1619990652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619990652 NPI number — DR. JENNIFER GOODE EDWARDS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
JENNIFER
Provider Middle Name:
GOODE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDWARDS
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
LEATRICE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619990652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 74365
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23236-0007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-745-3011
Provider Business Mailing Address Fax Number:
804-745-3012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9409 HULL STREET RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23236-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-745-3011
Provider Business Practice Location Address Fax Number:
804-745-3012
Provider Enumeration Date:
07/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0103300803 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9303502 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".