Provider Demographics
NPI:1760635734
Name:GONZALEZ, JESENIA
Entity Type:Individual
Prefix:
First Name:JESENIA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JESENIA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC BIL-SLP TSHH
Mailing Address - Street 1:30 EAST 22 STREET
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NEW YORK
Mailing Address - Zip Code:11746
Mailing Address - Country:UM
Mailing Address - Phone:631-223-2112
Mailing Address - Fax:
Practice Address - Street 1:30 E 22ND ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3210
Practice Address - Country:US
Practice Address - Phone:631-223-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist