Provider Demographics
NPI:1366644072
Name:GONZALEZ, JESSICA (OTL)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CALLE JUAN SOTO
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685-1705
Mailing Address - Country:US
Mailing Address - Phone:787-926-1764
Mailing Address - Fax:
Practice Address - Street 1:CALLE MATIAS BRUGMAN #341
Practice Address - Street 2:
Practice Address - City:LAS MARIAS
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-827-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist