Provider Demographics
NPI:1891389722
Name:GOUGH, MARISSA JORDYN
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JORDYN
Last Name:GOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:JORDYN
Other - Last Name:BOURGEOIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 N HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-3811
Mailing Address - Country:US
Mailing Address - Phone:580-688-2800
Mailing Address - Fax:
Practice Address - Street 1:111 N HUDSON ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3811
Practice Address - Country:US
Practice Address - Phone:580-688-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator