Provider Demographics
NPI:1215490479
Name:GONZALEZ, JESSICA CAROL (LMFTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CAROL
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21727 76TH AVE W STE J
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21727 76TH AVE W STE J
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7545
Practice Address - Country:US
Practice Address - Phone:206-362-7282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61153497261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)