Provider Demographics
NPI:1982943494
Name:GOUGE, JACQUELINE A (APNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:GOUGE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 RIVERSIDE AVE
Mailing Address - Street 2:GATE B BUILDING 1
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1123
Mailing Address - Country:US
Mailing Address - Phone:715-732-2078
Mailing Address - Fax:
Practice Address - Street 1:2741 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3833
Practice Address - Country:US
Practice Address - Phone:715-732-1392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5222-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704302472OtherMICHIGAN LICENSE
MIN41200026Medicare Oscar/Certification
WI401600089Medicare Oscar/Certification