Healthcare Provider Details

I. General information

NPI: 1760842553
Provider Name (Legal Business Name): JAYLYNG GOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 YARMOUTH AVE
BOULDER CO
80304-0564
US

IV. Provider business mailing address

1143 PORTLAND PL #4
BOULDER CO
80304-8217
US

V. Phone/Fax

Practice location:
  • Phone: 303-786-9314
  • Fax:
Mailing address:
  • Phone: 720-749-3527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: