Provider Demographics
NPI:1104423268
Name:GOEGLEIN, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GOEGLEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-3203
Mailing Address - Country:US
Mailing Address - Phone:601-209-0329
Mailing Address - Fax:
Practice Address - Street 1:1855 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4913
Practice Address - Country:US
Practice Address - Phone:601-366-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional