Provider Demographics
NPI:1851814487
Name:GONZALEZ IBARRA, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:GONZALEZ IBARRA
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 1:14763 SW 171ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-1776
Mailing Address - Country:US
Mailing Address - Phone:786-339-7028
Mailing Address - Fax:
Practice Address - Street 1:13205 SW 137TH AVE STE 222
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186
Practice Address - Country:US
Practice Address - Phone:305-200-6241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician