Healthcare Provider Details

I. General information

NPI: 1518185693
Provider Name (Legal Business Name): JENNIFER M GOODWIN FNP C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 CEDAR LN STE 900 BLDG B
TULLAHOMA TN
37388-2286
US

IV. Provider business mailing address

PO BOX 1327 1330 CEDAR LANE BLDG B SUITE 900
TULLAHOMA TN
37388-1327
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-2674
  • Fax: 931-455-8983
Mailing address:
  • Phone: 931-455-2674
  • Fax: 931-455-8983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN11120
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPN11120
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: