Provider Demographics
NPI:1154744076
Name:GOULD, JESSIE
Entity type:Individual
Prefix:MISS
First Name:JESSIE
Middle Name:
Last Name:GOULD
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 1:212 SPIRAL RD
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13 THOMPSON HAY PATH
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1317
Practice Address - Country:US
Practice Address - Phone:631-751-0197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor