Healthcare Provider Details

I. General information

NPI: 1245185966
Provider Name (Legal Business Name): JENNY LYNN GOEDDEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 NEW PETERSBURG DR STE D
AUGUSTA GA
30907-1920
US

IV. Provider business mailing address

205 NEW PETERSBURG DR
AUGUSTA GA
30907-1919
US

V. Phone/Fax

Practice location:
  • Phone: 706-251-7800
  • Fax:
Mailing address:
  • Phone: 706-251-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT1108882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: