Provider Demographics
NPI:1346735867
Name:GONZALES, JACQUELINE (MPCC, BS,CDCA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MPCC, BS,CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BOWMAN ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-1235
Mailing Address - Country:US
Mailing Address - Phone:419-525-3525
Mailing Address - Fax:
Practice Address - Street 1:400 BOWMAN ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-1235
Practice Address - Country:US
Practice Address - Phone:419-525-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165387101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)