Healthcare Provider Details

I. General information

NPI: 1932064417
Provider Name (Legal Business Name): JESSE JAMES GODDARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 E VIKING RD
LAS VEGAS NV
89169-3356
US

IV. Provider business mailing address

2320 E VIKING RD
LAS VEGAS NV
89169-3356
US

V. Phone/Fax

Practice location:
  • Phone: 720-404-0394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: