Provider Demographics
NPI:1720863962
Name:GONZALES, JAKE ANTHONY
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:ANTHONY
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 S BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024
Mailing Address - Country:US
Mailing Address - Phone:626-771-7711
Mailing Address - Fax:
Practice Address - Street 1:145 S BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024
Practice Address - Country:US
Practice Address - Phone:626-771-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer