Provider Demographics
NPI: | 1457813081 |
---|---|
Name: | GONZALEZ, JENNIFER (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | |
Last Name: | GONZALEZ |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 1189 |
Mailing Address - Street 2: | |
Mailing Address - City: | CORVALLIS |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97339-1189 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | SAMARITAN MENTAL HEALTH - CIRCLE BLVD |
Practice Address - Street 2: | 1112 NW CIRCLE BLVD |
Practice Address - City: | CORVALLIS |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97330-1462 |
Practice Address - Country: | US |
Practice Address - Phone: | 541-768-1221 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2019-04-02 |
Last Update Date: | 2022-07-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AR | E13577 | 2084N0400X |
390200000X | ||
OR | MD210593 | 2084P0804X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |