Healthcare Provider Details

I. General information

NPI: 1407776644
Provider Name (Legal Business Name): JEVON GOODEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21273 26TH AVE
BAYSIDE NY
11360-1943
US

IV. Provider business mailing address

12043 164TH ST
JAMAICA NY
11434-5740
US

V. Phone/Fax

Practice location:
  • Phone: 646-688-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: