Provider Demographics
NPI:1376862037
Name:GONZALEZ, JAIME (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER JOINT BASE LEWIS-MCCHORD
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-4849
Mailing Address - Fax:253-968-3731
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:9040 JACKSON AVE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98531
Practice Address - Country:US
Practice Address - Phone:253-968-4849
Practice Address - Fax:253-968-3731
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60778412103TC0700X
MNLP5426103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical