=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205878105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER CELESTE GOODFRED D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 05/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8970 WINCHESTER RD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38125-8231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-794-5806
-----------------------------------------------------
Fax | 901-794-7922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9398 DOGWOOD RD S
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38139-5737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-378-4705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 24106
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 1711
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------