Provider Demographics
NPI:1053127233
Name:GOODMAN, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ERIN CT
Mailing Address - Street 2:
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691-2527
Mailing Address - Country:US
Mailing Address - Phone:848-459-4082
Mailing Address - Fax:
Practice Address - Street 1:400 BELCHASE DR
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-9758
Practice Address - Country:US
Practice Address - Phone:694-773-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01215000225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics