Provider Demographics
NPI:1336624915
Name:GONZALES, JENNIFER PATRICIA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PATRICIA
Last Name:GONZALES
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 1:160 WIKIUP DR STE 102
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 WIKIUP DR STE 102
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7776
Practice Address - Country:US
Practice Address - Phone:707-483-3745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12575826OtherKAISER