Healthcare Provider Details

I. General information

NPI: 1972451771
Provider Name (Legal Business Name): JEREL LEMAR GOFORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 VIRGINIA BEACH BLVD
VIRGINIA BEACH VA
23454-4533
US

IV. Provider business mailing address

5605 LARRY AVE
VIRGINIA BEACH VA
23462-1713
US

V. Phone/Fax

Practice location:
  • Phone: 844-909-2375
  • Fax:
Mailing address:
  • Phone: 773-733-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: