Healthcare Provider Details

I. General information

NPI: 1043568173
Provider Name (Legal Business Name): JESSICA ANN GODOVIN AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 W CHESTER PIKE STE 280 AUDIOLOGY DEPARTMENT
NEWTOWN SQUARE PA
19073-2304
US

IV. Provider business mailing address

PO BOX 191 AUDIOLOGY DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 610-557-4800
  • Fax: 610-557-4816
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberO2-0000193
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAT006265
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License NumberO2-0000193
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License NumberAT006265
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License NumberO2-0000193
License Number StateDE
# 6
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License NumberAT006265
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberO2-0000193
License Number StateDE
# 8
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAT006265
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: