Provider Demographics
NPI:1356126239
Name:GONZALES, JESSICA M
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
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 1:6502 BANDERA RD STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1454
Mailing Address - Country:US
Mailing Address - Phone:210-325-7156
Mailing Address - Fax:
Practice Address - Street 1:5282 MEDICAL DR STE 240
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4849
Practice Address - Country:US
Practice Address - Phone:210-358-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX657701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty