=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588019947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA RYAN JACQUES GOODMAN OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2016
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1166 FARMINGTON AVE
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-2351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-829-8939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1166 FARMINGTON AVE
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-2351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-829-8939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901004996
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3377
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------