Provider Demographics
NPI:1205339124
Name:GONZALEZ, JESSICA MARIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:GONZALEZ
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 1:3925 NORTH MARTIN LUTHER KING BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032
Mailing Address - Country:US
Mailing Address - Phone:702-684-7757
Mailing Address - Fax:702-684-7381
Practice Address - Street 1:3925 NORTH MARTIN LUTHER KING BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-684-7757
Practice Address - Fax:702-684-7381
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health