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General NPI Number Information
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NPI Number | 1124137765
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Entity Type | Individual
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Provider Name | JERRY M GOFFMAN PHD.
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Gender | Male
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 10/01/2007
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Provider Practice Location Address
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Address Line | 8253 WHITE OAK AVE
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-7671
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Country | US
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Telephone | 951-312-1041
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Fax |
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Provider Business Mailing Address
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Address Line | 1040 S MOUNT VERNON AVE G-306
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City | COLTON
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State | CA
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Zip | 92324-4228
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Country | US
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Telephone | 951-312-1041
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY7081
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License Number State | CA
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