Provider Demographics
NPI:1518603091
Name:GONZALEZ, JAZMIN
Entity Type:Individual
Prefix:
First Name:JAZMIN
Middle Name:
Last Name:GONZALEZ
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 1:5704 EUPER LN STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3256
Mailing Address - Country:US
Mailing Address - Phone:479-242-4480
Mailing Address - Fax:405-336-3008
Practice Address - Street 1:5704 EUPER LN STE 100
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3256
Practice Address - Country:US
Practice Address - Phone:479-242-4480
Practice Address - Fax:405-336-3008
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician