Healthcare Provider Details

I. General information

NPI: 1891433488
Provider Name (Legal Business Name): JESSICA ROSE GOLDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W BROAD ST STE 400
RICHMOND VA
23230-1709
US

IV. Provider business mailing address

PO BOX 13289
DURHAM NC
27709-3289
US

V. Phone/Fax

Practice location:
  • Phone: 804-774-4550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: