Provider Demographics
NPI:1215534946
Name:GONZALEZ, JODIE LYNN (LAC,LASAC)
Entity Type:Individual
Prefix:MS
First Name:JODIE
Middle Name:LYNN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LAC,LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20430 W CARLA VISTA
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-4698
Mailing Address - Country:US
Mailing Address - Phone:602-505-3797
Mailing Address - Fax:
Practice Address - Street 1:20430 W CARLA VISTA
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-4698
Practice Address - Country:US
Practice Address - Phone:602-505-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-155232101YA0400X
AZLASAC-15240101YA0400X
AZLAC-16287101YM0800X
AZLPC-19626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health