Provider Demographics
NPI:1093537581
Name:MOGUSH, JAIMIE ALLENE (ARNP)
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:ALLENE
Last Name:MOGUSH
Suffix:
Gender:
Credentials:ARNP
Other - Prefix:
Other - First Name:JAIMIE
Other - Middle Name:
Other - Last Name:HINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:CATHLAMET
Mailing Address - State:WA
Mailing Address - Zip Code:98612
Mailing Address - Country:US
Mailing Address - Phone:360-606-4638
Mailing Address - Fax:
Practice Address - Street 1:1302 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-606-4638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61617758363L00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily