Healthcare Provider Details

I. General information

NPI: 1174129381
Provider Name (Legal Business Name): JENNIFER GOODIN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 MARKET ST STE C
MOUNT CLEMENS MI
48043-7403
US

IV. Provider business mailing address

1943 HOLLAND AVE
PORT HURON MI
48060-1519
US

V. Phone/Fax

Practice location:
  • Phone: 586-783-2222
  • Fax: 583-783-6380
Mailing address:
  • Phone: 810-357-4945
  • Fax: 810-985-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704281359
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: