Provider Demographics
NPI:1891330759
Name:GOOCH, JADA
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:GOOCH
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 1:945 WINDRIDGE CT APT A
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4797
Mailing Address - Country:US
Mailing Address - Phone:607-793-3397
Mailing Address - Fax:
Practice Address - Street 1:945 WINDRIDGE CT APT A
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4797
Practice Address - Country:US
Practice Address - Phone:607-793-3397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19902225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist