Provider Demographics
NPI:1851533467
Name:GONZALEZ, JAIRO E
Entity Type:Individual
Prefix:
First Name:JAIRO
Middle Name:E
Last Name:GONZALEZ
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 1:1366 SW 180TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-4910
Mailing Address - Country:US
Mailing Address - Phone:305-450-4674
Mailing Address - Fax:
Practice Address - Street 1:1366 SW 180TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-4910
Practice Address - Country:US
Practice Address - Phone:305-450-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-04-1403103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst