Basic Information
| Provider Information | |||||||||
| NPI: | 1558824136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | JEANINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 LINCOLN ST APT 101 | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970243772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033815577 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 BEAVERCREEK RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.