Healthcare Provider Details

I. General information

NPI: 1508778259
Provider Name (Legal Business Name): JACQUELINE NICOLE GOODWYN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9803 JACQUELINE DR
FORT WASHINGTON MD
20744-2526
US

IV. Provider business mailing address

9803 JACQUELINE DR
FORT WASHINGTON MD
20744-2526
US

V. Phone/Fax

Practice location:
  • Phone: 301-792-4799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: