Provider Demographics
NPI:1598523318
Name:GONZALEZ MORENO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GONZALEZ MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MORENO VIZCARRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4126 JASON AVE NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-3061
Mailing Address - Country:US
Mailing Address - Phone:612-355-0344
Mailing Address - Fax:
Practice Address - Street 1:2021 E HENNEPIN AVE STE LL20
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2738
Practice Address - Country:US
Practice Address - Phone:612-259-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst