Provider Demographics
NPI:1609590587
Name:GONZALEZ, JESUS ABRAHAM
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ABRAHAM
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 RIVER RUN DR APT 8102
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5851
Mailing Address - Country:US
Mailing Address - Phone:619-302-8949
Mailing Address - Fax:
Practice Address - Street 1:2285 RIVER RUN DR APT 8102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-5851
Practice Address - Country:US
Practice Address - Phone:619-302-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12970485OtherMEXICAN BOARD OF PSHYCOLOGISTS