Provider Demographics
NPI:1043994130
Name:GONZALEZ, JAIZIE (PTA)
Entity Type:Individual
Prefix:
First Name:JAIZIE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 STRATOFORTRESS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5170
Mailing Address - Country:US
Mailing Address - Phone:209-726-9000
Mailing Address - Fax:
Practice Address - Street 1:3009 STRATOFORTRESS AVE STE B
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-5170
Practice Address - Country:US
Practice Address - Phone:209-726-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48672225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant