Provider Demographics
NPI:1083983068
Name:GONZALES, JENNIFER LAZARO (RPT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LAZARO
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:TONGOL
Other - Last Name:LAZARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 E NAYLOR MILL RD UNIT F
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2308
Mailing Address - Country:US
Mailing Address - Phone:302-331-0134
Mailing Address - Fax:
Practice Address - Street 1:701 E NAYLOR MILL RD UNIT F
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-2308
Practice Address - Country:US
Practice Address - Phone:302-331-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist