Provider Demographics
NPI:1205578598
Name:GOODEN, JENIENNE ELIZABETH
Entity type:Individual
Prefix:MS
First Name:JENIENNE
Middle Name:ELIZABETH
Last Name:GOODEN
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 1:1674 SOUTHEAST FALLON DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983
Mailing Address - Country:US
Mailing Address - Phone:772-834-5733
Mailing Address - Fax:
Practice Address - Street 1:1674 SOUTH EAST FALLON DRIVE
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983
Practice Address - Country:US
Practice Address - Phone:772-834-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home