Provider Demographics
NPI:1861946402
Name:GOODMAN, JEROLYN MAE (RDN, LD)
Entity type:Individual
Prefix:MS
First Name:JEROLYN
Middle Name:MAE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 MERCEDES ST
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-2809
Mailing Address - Country:US
Mailing Address - Phone:817-249-2423
Mailing Address - Fax:
Practice Address - Street 1:1405 MERCEDES ST
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-2809
Practice Address - Country:US
Practice Address - Phone:817-249-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84176133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered