Provider Demographics
NPI:1013093046
Name:GONZALEZ, JENNIFER (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 WHITEWING AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-4057
Mailing Address - Country:US
Mailing Address - Phone:956-874-3327
Mailing Address - Fax:
Practice Address - Street 1:1300 N 10TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-4392
Practice Address - Country:US
Practice Address - Phone:956-630-6066
Practice Address - Fax:956-630-6069
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103108235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208531801OtherMEDICAID TPI