Provider Demographics
NPI:1376859215
Name:GONZALEZ, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9528 S AVENUE L
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-5120
Mailing Address - Country:US
Mailing Address - Phone:773-933-1627
Mailing Address - Fax:
Practice Address - Street 1:9528 S AVENUE L
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-5120
Practice Address - Country:US
Practice Address - Phone:773-933-1627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional