Provider Demographics
NPI:1679194625
Name:GONZALEZ, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7971 SW 152ND AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3222
Mailing Address - Country:US
Mailing Address - Phone:786-241-9865
Mailing Address - Fax:
Practice Address - Street 1:7971 SW 152ND AVE APT 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-3222
Practice Address - Country:US
Practice Address - Phone:786-241-9865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-116695106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician