Healthcare Provider Details

I. General information

NPI: 1487370359
Provider Name (Legal Business Name): JENNIFER GOOD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

IV. Provider business mailing address

PO BOX 28164
SANTA FE NM
87592-8164
US

V. Phone/Fax

Practice location:
  • Phone: 505-216-2727
  • Fax:
Mailing address:
  • Phone: 505-501-8974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1677945
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: