Healthcare Provider Details

I. General information

NPI: 1013840073
Provider Name (Legal Business Name): JENNY KISSELL GOOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PAGE RD N STE 2
PINEHURST NC
28374-4607
US

IV. Provider business mailing address

155 MEMORIAL DR
PINEHURST NC
28374-8710
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-1064
  • Fax:
Mailing address:
  • Phone: 910-715-1064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number26026
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: