MEDICARE: JODY LYNN GOODSON PT

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	225100000X	Physical Therapist	5501013037	MI

General Provider Information

NPI Number	:	1619447752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODY LYNN GOODSON PT

Provider Business Mailing Address
First Line	:	8833 BEECHWOOD CT
Second Line	:
City	:	BERRIEN CENTER
State	:	MI
Zip	:	49102-8721
Country	:	US
Telephone Number	:	269-357-3737
Fax Number	:

Provider Business Practice Location Address
First Line	:	4066 RED ARROW HWY STE A
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-9209
Country	:	US
Telephone Number	:	269-408-0494
Fax Number	:	269-408-0492

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

Provider Enumeration Date	:	12/02/2018
Last Update Date	:	12/02/2018

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