Provider Demographics
NPI:1316600182
Name:GONZALEZ, JESSIE (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7239
Mailing Address - Country:US
Mailing Address - Phone:718-299-1100
Mailing Address - Fax:
Practice Address - Street 1:3940 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1534
Practice Address - Country:US
Practice Address - Phone:212-781-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13374104100000X
NY113374104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker