Provider Demographics
NPI:1659133411
Name:GONZALES, JESSE RAY
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:RAY
Last Name:GONZALES
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 1:14675 NORFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1361
Mailing Address - Country:US
Mailing Address - Phone:909-248-5300
Mailing Address - Fax:
Practice Address - Street 1:12100 WILSHIRE BLVD STE 836
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7120
Practice Address - Country:US
Practice Address - Phone:516-590-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1056065106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician