MEDICARE: JESSICA RYAN JACQUES-GOODMAN OD

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	152W00000X	Optometrist	3377	CT
2	152W00000X	Optometrist	4901004996	MI

General Provider Information

NPI Number	:	1588019947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RYAN JACQUES-GOODMAN OD

Provider Business Mailing Address
First Line	:	1166 FARMINGTON AVE
Second Line	:
City	:	BERLIN
State	:	CT
Zip	:	06037-2351
Country	:	US
Telephone Number	:	860-829-8939
Fax Number	:

Provider Business Practice Location Address
First Line	:	1166 FARMINGTON AVE
Second Line	:
City	:	BERLIN
State	:	CT
Zip	:	06037-2351
Country	:	US
Telephone Number	:	860-829-8939
Fax Number	:

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

Provider Enumeration Date	:	05/03/2016
Last Update Date	:	03/26/2026

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