=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023762432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA GOODSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2022
-----------------------------------------------------
Last Update Date | 02/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18037 RIDGEWOOD AVE
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60438-2253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-400-9409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6411 238TH AVE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53168-9637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------