MEDICARE: JACQUELINE H GOODIN LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I5454	OH

General Provider Information

NPI Number	:	1003810664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE H GOODIN LISW

Provider Business Mailing Address
First Line	:	1439 MARLOWE AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-4318
Country	:	US
Telephone Number	:	216-226-6851
Fax Number	:

Provider Business Practice Location Address
First Line	:	3430 ROCKY RIVER DR
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-2954
Country	:	US
Telephone Number	:	216-688-1111
Fax Number	:	216-251-2886

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	07/08/2007

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