Provider Demographics
NPI:1801317383
Name:GOGG, JESSIE WATTS (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:WATTS
Last Name:GOGG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-3376
Mailing Address - Country:US
Mailing Address - Phone:704-530-8341
Mailing Address - Fax:
Practice Address - Street 1:138 SHEPHERD RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115
Practice Address - Country:US
Practice Address - Phone:704-530-8341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0101801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical