Healthcare Provider Details

I. General information

NPI: 1588534580
Provider Name (Legal Business Name): MIGUEL DUPREE MCGAUGHY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 REX AVE
JACKSON CA
95642-2020
US

IV. Provider business mailing address

217 REX AVE
JACKSON CA
95642-2020
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-5308
  • Fax: 209-223-1733
Mailing address:
  • Phone: 209-257-5308
  • Fax: 209-223-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number220085982
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: