Provider Demographics
NPI:1255175147
Name:GONZALEZ, JACOB (MA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 WYOMING AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5759
Mailing Address - Country:US
Mailing Address - Phone:915-777-9023
Mailing Address - Fax:
Practice Address - Street 1:800 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3954
Practice Address - Country:US
Practice Address - Phone:575-526-2819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool