Provider Demographics
NPI:1922539576
Name:GOODEN, JEROME M (MED)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:M
Last Name:GOODEN
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13427 166TH PL APT 7H
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3832
Mailing Address - Country:US
Mailing Address - Phone:646-242-3245
Mailing Address - Fax:
Practice Address - Street 1:13427 166TH PL APT 7H
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3832
Practice Address - Country:US
Practice Address - Phone:646-242-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst