Provider Demographics
NPI:1073167425
Name:GONZALES, JENNY R (COTA)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:R
Last Name:GONZALES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5760 HERMOSA CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-2061
Mailing Address - Country:US
Mailing Address - Phone:904-625-2698
Mailing Address - Fax:
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-7355
Practice Address - Country:US
Practice Address - Phone:850-698-4849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13206224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant