Provider Demographics
NPI:1346895653
Name:GONZALES, JESSICA LEE (MS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:GRZEGORZEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2189 EAGLE TALON CIR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4046
Mailing Address - Country:US
Mailing Address - Phone:847-530-5567
Mailing Address - Fax:
Practice Address - Street 1:1851 GOLDEN EAGLE WAY STE 43
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4334
Practice Address - Country:US
Practice Address - Phone:904-374-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist