Provider Demographics
NPI:1619370673
Name:GONZALES, JESSICA LYNN (SLP)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LYNN
Last Name:GONZALES
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-3859
Mailing Address - Country:US
Mailing Address - Phone:956-399-8900
Mailing Address - Fax:866-571-2523
Practice Address - Street 1:175 E ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-3859
Practice Address - Country:US
Practice Address - Phone:956-399-8900
Practice Address - Fax:866-571-2523
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist