Provider Demographics
NPI:1588799639
Name:GOULD, JACQUELYNN MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYNN
Middle Name:MICHELLE
Last Name:GOULD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 W MOUNTAIN VIEW AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3178
Mailing Address - Country:US
Mailing Address - Phone:303-651-5302
Mailing Address - Fax:
Practice Address - Street 1:4021 AVENUE B
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4602
Practice Address - Country:US
Practice Address - Phone:308-630-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44789207Q00000X
NE30619208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine