Healthcare Provider Details

I. General information

NPI: 1497498844
Provider Name (Legal Business Name): JENEE CYMONE GOODEN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 GRANT ST
BRIDGEPORT CT
06610-2805
US

IV. Provider business mailing address

4837 STONY HILL ST
NORTH LAS VEGAS NV
89031-5123
US

V. Phone/Fax

Practice location:
  • Phone: 203-384-3998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1395-25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: