Provider Demographics
NPI:1831473701
Name:MCGOUGH, JENNIFER ANN (LPCC, LADAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:LPCC, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11133 ACADEMY RIDGE RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6868
Mailing Address - Country:US
Mailing Address - Phone:505-274-2946
Mailing Address - Fax:
Practice Address - Street 1:3604 MARY ELLEN ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-274-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0154281101YA0400X
NM0198021101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)