Healthcare Provider Details

I. General information

NPI: 1609248202
Provider Name (Legal Business Name): JESSE GOODMAN AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17782 COWAN STE A
IRVINE CA
92614-6041
US

IV. Provider business mailing address

28411 PUEBLO DR
TRABUCO CANYON CA
92679-1157
US

V. Phone/Fax

Practice location:
  • Phone: 949-722-7118
  • Fax:
Mailing address:
  • Phone: 801-425-2831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95003286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: