Provider Demographics
NPI:1467648121
Name:GOGAN, JANE B (PHD, ABPP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:B
Last Name:GOGAN
Suffix:
Gender:F
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 WOODLAND TRL
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3015 WOODLAND TRL
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-1910
Practice Address - Country:US
Practice Address - Phone:608-467-3412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2571 057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical