MEDICARE: JAMESEN L. GOODMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LC2431	MD

General Provider Information

NPI Number	:	1053533323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMESEN L. GOODMAN

Provider Business Mailing Address
First Line	:	512 DARTMOUTH AVE.
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910
Country	:	US
Telephone Number	:	301-589-5821
Fax Number	:

Provider Business Practice Location Address
First Line	:	8555 16TH ST STE 202
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-2802
Country	:	US
Telephone Number	:	301-589-6033
Fax Number	:	301-589-1039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/16/2012

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