Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 090186 | IA |
N | 103T00000X | Psychologist | 090186 | IA |
N | 103G00000X | Clinical Psychologist | 090186 | IA |
N | 103TC0700X | Clinical Psychologist | 090186 | IA |
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 090186 | IA |
NPI | 1134601826 |
---|---|
Provider Name | Jon W Goodwin III |
First Address | Iowa City, IA 52242-1009 |
Second Address | Iowa City, IA 52242-1009 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2018 |
Last Update Date | 04/06/2019 |