Provider Demographics
NPI:1376836866
Name:GOUGHNOUR, JARED PAUL (PTA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:PAUL
Last Name:GOUGHNOUR
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HIGHSPIRE
Mailing Address - State:PA
Mailing Address - Zip Code:17034-1506
Mailing Address - Country:US
Mailing Address - Phone:717-649-0055
Mailing Address - Fax:
Practice Address - Street 1:524 2ND ST
Practice Address - Street 2:
Practice Address - City:HIGHSPIRE
Practice Address - State:PA
Practice Address - Zip Code:17034-1506
Practice Address - Country:US
Practice Address - Phone:717-649-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI001301225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant