Provider Demographics
NPI:1750654513
Name:GONZALES, JESSIE CAMILLE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:CAMILLE
Last Name:GONZALES
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 1:729 PELHAM PKWY N
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-9506
Mailing Address - Country:US
Mailing Address - Phone:718-944-5050
Mailing Address - Fax:718-944-1418
Practice Address - Street 1:729 PELHAM PKWY N
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-9506
Practice Address - Country:US
Practice Address - Phone:718-944-5050
Practice Address - Fax:718-944-1418
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP82652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist