1184188419 NPI number — MRS. JENNIFER OLLIE GOODRICH LCPC

Table of content: MRS. JENNIFER OLLIE GOODRICH LCPC (NPI 1184188419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184188419 NPI number — MRS. JENNIFER OLLIE GOODRICH LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODRICH
Provider First Name:
JENNIFER
Provider Middle Name:
OLLIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184188419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12610 S THROOP ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALUMET PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60827-6115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12610 S THROOP ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALUMET PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60827-6115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-715-5167
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2019

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: 101YP2500X , with the licence number:  180010639 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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