Provider Demographics
NPI:1780989160
Name:GOODFELLOW, JESSICA K (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:K
Last Name:GOODFELLOW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 SW 44TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8046
Mailing Address - Country:US
Mailing Address - Phone:580-574-0801
Mailing Address - Fax:
Practice Address - Street 1:21065 POWERLINE RD
Practice Address - Street 2:SUITE A 2
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-2313
Practice Address - Country:US
Practice Address - Phone:561-883-7800
Practice Address - Fax:561-883-7801
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT4330225100000X
FL27762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist