Healthcare Provider Details

I. General information

NPI: 1003810664
Provider Name (Legal Business Name): JACQUELINE H GOODIN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 ROCKY RIVER DR
CLEVELAND OH
44111-2954
US

IV. Provider business mailing address

1439 MARLOWE AVE
LAKEWOOD OH
44107-4318
US

V. Phone/Fax

Practice location:
  • Phone: 216-688-1111
  • Fax: 216-251-2886
Mailing address:
  • Phone: 216-226-6851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI5454
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: