Provider Demographics
NPI:1073067765
Name:GOUGH, JACOB EDWARD
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:EDWARD
Last Name:GOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 U ST NW
Mailing Address - Street 2:#300
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-7991
Mailing Address - Country:US
Mailing Address - Phone:202-888-5595
Mailing Address - Fax:
Practice Address - Street 1:1330 U ST NW
Practice Address - Street 2:#300
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-7991
Practice Address - Country:US
Practice Address - Phone:202-888-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMT1418225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist