Provider Demographics
NPI:1841857612
Name:GOMEZ, JASMINE E
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:E
Last Name:GOMEZ
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 1:8315 ARGOS RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:29 PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277
Mailing Address - Country:US
Mailing Address - Phone:951-484-8910
Mailing Address - Fax:
Practice Address - Street 1:8315 ARGOS RD
Practice Address - Street 2:UNIT A
Practice Address - City:29 PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277
Practice Address - Country:US
Practice Address - Phone:951-484-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-87351106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician