Provider Demographics
NPI:1952863698
Name:GONZALEZ, JIMMY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
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 1:14425 EADBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-2559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14425 EADBROOK DR
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-2559
Practice Address - Country:US
Practice Address - Phone:626-315-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X, 247200000X
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty