Provider Demographics
NPI:1841739224
Name:GONZALES, JESSICA DANIELLE (MED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2001 N 3RD ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1495
Practice Address - Country:US
Practice Address - Phone:602-922-6760
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-001816103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-24-76122OtherBCBA CERTIFICATE