Provider Demographics
NPI:1376276527
Name:GONZALEZ ETHEREDGE, JOCELYN
Entity Type:Individual
Prefix:
First Name:JOCELYN
Middle Name:
Last Name:GONZALEZ ETHEREDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10860 TRESTLE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-3336
Mailing Address - Country:US
Mailing Address - Phone:904-412-1646
Mailing Address - Fax:
Practice Address - Street 1:3547 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5309
Practice Address - Country:US
Practice Address - Phone:904-877-1100
Practice Address - Fax:904-877-1200
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9382630163WP0808X
FLAPRN11021202363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health