Provider Demographics
NPI:1902136187
Name:GOODWIN, JESSICA R (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:R
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:BROOKE
Other - Last Name:RHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:507 DRUID DR
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-7076
Mailing Address - Country:US
Mailing Address - Phone:713-826-9733
Mailing Address - Fax:
Practice Address - Street 1:500 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7354
Practice Address - Country:US
Practice Address - Phone:903-870-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2141953Medicaid
LA3C435C734Medicare PIN