Provider Demographics
NPI:1821323379
Name:GONZALEZ, JACQUELINE (AMFT 113958)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:AMFT 113958
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9570 CENTER AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5842
Mailing Address - Country:US
Mailing Address - Phone:909-980-2789
Mailing Address - Fax:909-980-2689
Practice Address - Street 1:9570 CENTER AVE STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5842
Practice Address - Country:US
Practice Address - Phone:909-980-2789
Practice Address - Fax:909-980-2689
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CARS3295101YA0400X
CA113958106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)