Provider Demographics
NPI:1659996494
Name:GOMEZ TLACOXOLAL, JOSE MANUEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:GOMEZ TLACOXOLAL
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 1:3140 RUBINO DR APT 220
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-6390
Mailing Address - Country:US
Mailing Address - Phone:831-214-6289
Mailing Address - Fax:
Practice Address - Street 1:1144 S 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5974
Practice Address - Country:US
Practice Address - Phone:408-230-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
CA97149104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker