Provider Demographics
NPI:1497824403
Name:GOUGH, JENNA JILL (MSW)
Entity Type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:JILL
Last Name:GOUGH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 SUNRISE DR
Mailing Address - Street 2:SUITE #2G
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-2178
Mailing Address - Country:US
Mailing Address - Phone:805-937-4259
Mailing Address - Fax:
Practice Address - Street 1:1722 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-570-8688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3856104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker