Provider Demographics
NPI:1003449034
Name:GONZALEZ, JAMIE (SSP, NCSP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 SW 93RD PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-1565
Mailing Address - Country:US
Mailing Address - Phone:786-376-1094
Mailing Address - Fax:
Practice Address - Street 1:9260 SW 72ND ST STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3255
Practice Address - Country:US
Practice Address - Phone:786-376-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1411103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool