Provider Demographics
NPI:1760273585
Name:GOODWIN, JEANNENE
Entity type:Individual
Prefix:
First Name:JEANNENE
Middle Name:
Last Name:GOODWIN
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 1:42590 STEPNITZ DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3161
Mailing Address - Country:US
Mailing Address - Phone:586-954-1838
Mailing Address - Fax:
Practice Address - Street 1:42590 STEPNITZ DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-3161
Practice Address - Country:US
Practice Address - Phone:586-954-1838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703063896164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse