MEDICARE: MISS JENNA JILL GOUGH MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	3856	CA

General Provider Information

NPI Number	:	1497824403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JENNA JILL GOUGH MSW

Provider Business Mailing Address
First Line	:	610 SUNRISE DR
Second Line	:	SUITE #2G
City	:	SANTA MARIA
State	:	CA
Zip	:	93455-2178
Country	:	US
Telephone Number	:	805-937-4259
Fax Number	:

Provider Business Practice Location Address
First Line	:	1722 S LEWIS RD
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-8520
Country	:	US
Telephone Number	:	805-570-8688
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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