Healthcare Provider Details

I. General information

NPI: 1174345359
Provider Name (Legal Business Name): JAIMIE GOODWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 MOORES RIVER DR
LANSING MI
48910-1434
US

IV. Provider business mailing address

584 PINESPAR DR SW
BYRON CENTER MI
49315-8371
US

V. Phone/Fax

Practice location:
  • Phone: 517-887-0226
  • Fax: 517-887-8121
Mailing address:
  • Phone: 616-312-7228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: