Basic Information
| Provider Information | |||||||||
| NPI: | 1700095064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODWIN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 W PROFESSIONAL PARK CT STE 1 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | 2707779283 | ||||||||
| Practice Location | |||||||||
| Address1: | 2460 INDIA HOOK RD STE AND105 | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297323530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033666250 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-6-3183 | SC | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | EX6562 | 05 | SC | MEDICAID |