Provider Demographics
NPI:1538364567
Name:GOODSON, JASON TALLEY (PHD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:TALLEY
Last Name:GOODSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 BALA AVE
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-3025
Mailing Address - Country:US
Mailing Address - Phone:610-667-6490
Mailing Address - Fax:610-667-1744
Practice Address - Street 1:112 BALA AVE
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3025
Practice Address - Country:US
Practice Address - Phone:610-667-6490
Practice Address - Fax:610-667-1744
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017069103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist