Provider Demographics
NPI:1407394653
Name:GONZALEZ, JENNIFER (MED)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N TUSTIN AVE STE 228
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3735
Mailing Address - Country:US
Mailing Address - Phone:949-446-9938
Mailing Address - Fax:833-897-9774
Practice Address - Street 1:505 N TUSTIN AVE STE 228
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3735
Practice Address - Country:US
Practice Address - Phone:949-446-9938
Practice Address - Fax:833-897-9774
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-29614103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst