Provider Demographics
NPI:1558964163
Name:HERNANDEZ-GONZALES, JESSICA LASSETTE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LASSETTE
Last Name:HERNANDEZ-GONZALES
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2747
Mailing Address - Country:US
Mailing Address - Phone:360-430-0952
Mailing Address - Fax:
Practice Address - Street 1:3015 FLORIDA ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2747
Practice Address - Country:US
Practice Address - Phone:360-430-0952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61097960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist