Provider Demographics
NPI:1720304504
Name:GARCIA-GOMEZ, JOSE LUIS (MA, MS)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:GARCIA-GOMEZ
Suffix:
Gender:M
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SISKIYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2140
Mailing Address - Country:US
Mailing Address - Phone:541-292-0907
Mailing Address - Fax:
Practice Address - Street 1:600 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2140
Practice Address - Country:US
Practice Address - Phone:541-292-0907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3215101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health