Healthcare Provider Details

I. General information

NPI: 1376474098
Provider Name (Legal Business Name): DR. JACOB FORREST GOODMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E BROADWAY ST
BOLIVAR MO
65613-1625
US

IV. Provider business mailing address

305 E BROADWAY ST
BOLIVAR MO
65613-1625
US

V. Phone/Fax

Practice location:
  • Phone: 417-203-4121
  • Fax:
Mailing address:
  • Phone: 417-203-4121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026022880
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: