Provider Demographics
NPI:1972193118
Name:GONZALES, JESSICA ANGELLE
Entity Type:Individual
Prefix:
First Name:JESSICA ANGELLE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 LA TERRAZA CIR UNIT 301
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-7829
Mailing Address - Country:US
Mailing Address - Phone:951-818-2733
Mailing Address - Fax:
Practice Address - Street 1:1020 LA TERRAZA CIR UNIT 301
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-7829
Practice Address - Country:US
Practice Address - Phone:951-818-2733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95192649163W00000X
CA95028217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse