Healthcare Provider Details

I. General information

NPI: 1912589433
Provider Name (Legal Business Name): JENNIFER GOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 TECHNOLOGY CT STE 105
RIVERSIDE CA
92507-2181
US

IV. Provider business mailing address

525 TECHNOLOGY CT STE 105
RIVERSIDE CA
92507-2181
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: