Provider Demographics
NPI:1942773270
Name:JESSICA R. GONZALEZ, M.S., CCC-SLP, PLLC
Entity Type:Organization
Organization Name:JESSICA R. GONZALEZ, M.S., CCC-SLP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:956-735-9133
Mailing Address - Street 1:1328 W BLUE BONNET ST
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-4214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 W 2ND ST
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-3608
Practice Address - Country:US
Practice Address - Phone:956-735-9133
Practice Address - Fax:956-263-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1811273154OtherINDIVIDUAL NPI
TX287306901Medicaid