Provider Demographics
NPI:1891450235
Name:GONZALEZ, JAIME DANIEL
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:DANIEL
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 1:1099 NORIEGA AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-5828
Mailing Address - Country:US
Mailing Address - Phone:408-816-3237
Mailing Address - Fax:
Practice Address - Street 1:39210 STATE ST STE 220
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1456
Practice Address - Country:US
Practice Address - Phone:510-894-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461305562106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician