Provider Demographics
NPI:1942480769
Name:GOGAN, JENISE C (MA)
Entity Type:Individual
Prefix:MS
First Name:JENISE
Middle Name:C
Last Name:GOGAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3265
Mailing Address - Country:US
Mailing Address - Phone:253-697-8548
Mailing Address - Fax:253-697-8392
Practice Address - Street 1:325 E PIONEER AVE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3265
Practice Address - Country:US
Practice Address - Phone:253-697-8548
Practice Address - Fax:253-697-8392
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00044068101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health