Provider Demographics
NPI:1295412856
Name:GONZALEZ, JENNY LYNN
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
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 1:614 WATEREE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6635
Mailing Address - Country:US
Mailing Address - Phone:774-721-6252
Mailing Address - Fax:855-504-4089
Practice Address - Street 1:1640 ASHLEY HALL RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3824
Practice Address - Country:US
Practice Address - Phone:774-721-6452
Practice Address - Fax:855-504-4089
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5538224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant