Provider Demographics
NPI:1760842553
Name:GOUGH, JAYLYNG
Entity Type:Individual
Prefix:
First Name:JAYLYNG
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 PORTLAND PL
Mailing Address - Street 2:#4
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-8217
Mailing Address - Country:US
Mailing Address - Phone:720-749-3527
Mailing Address - Fax:
Practice Address - Street 1:1501 YARMOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-0564
Practice Address - Country:US
Practice Address - Phone:303-786-9314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health