Provider Demographics
NPI:1053533323
Name:GOODMAN, JAMESEN L
Entity type:Individual
Prefix:
First Name:JAMESEN
Middle Name:L
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 1:512 DARTMOUTH AVE.
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910
Mailing Address - Country:US
Mailing Address - Phone:301-589-5821
Mailing Address - Fax:
Practice Address - Street 1:8555 16TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-2802
Practice Address - Country:US
Practice Address - Phone:301-589-6033
Practice Address - Fax:301-589-1039
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health