Provider Demographics
NPI:1023590676
Name:GOUGE, JENNIFER DANIELLE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DANIELLE
Last Name:GOUGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DANIELLE
Other - Last Name:PRENTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1001 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-2907
Mailing Address - Country:US
Mailing Address - Phone:918-786-2243
Mailing Address - Fax:
Practice Address - Street 1:2036 S MILLER LN
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-1520
Practice Address - Country:US
Practice Address - Phone:918-739-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK97758363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner