Healthcare Provider Details

I. General information

NPI: 1821662495
Provider Name (Legal Business Name): JENNIVIA GOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3371 PARKER HILL RD
SANTA ROSA CA
95404-1732
US

IV. Provider business mailing address

3371 PARKER HILL RD
SANTA ROSA CA
95404-1732
US

V. Phone/Fax

Practice location:
  • Phone: 415-861-0828
  • Fax:
Mailing address:
  • Phone: 415-861-0828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: