Provider Demographics
NPI:1609171495
Name:GONZALES, JACIE (CLD)
Entity Type:Individual
Prefix:
First Name:JACIE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6824 S FRANKLIN CIR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-1322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6824 S FRANKLIN CIR
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122-1322
Practice Address - Country:US
Practice Address - Phone:303-941-8824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula