Provider Demographics
NPI:1265235832
Name:GONZALEZ HERNANDEZ, JENNY NIRVANA
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:NIRVANA
Last Name:GONZALEZ HERNANDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 PIONEER 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-7533
Mailing Address - Country:US
Mailing Address - Phone:863-677-7760
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LABELLE
Practice Address - State:FL
Practice Address - Zip Code:33935-4440
Practice Address - Country:US
Practice Address - Phone:239-544-8232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1293741106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician