Provider Demographics
NPI:1962886234
Name:GOUGE, JACQUELYN (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:GOUGE
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 WINKLER AVE
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-6249
Mailing Address - Country:US
Mailing Address - Phone:254-634-8505
Mailing Address - Fax:254-781-4312
Practice Address - Street 1:1102 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6249
Practice Address - Country:US
Practice Address - Phone:254-634-8505
Practice Address - Fax:254-681-0505
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
TX111381235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist