Provider Demographics
NPI:1952707986
Name:GONZALEZ, JENNIFER MARIE (PA-C, LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA-C, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-905-8998
Practice Address - Street 1:225 E 7TH ST
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5327
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-886-4282
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2023-04-28
Deactivation Date:2021-10-08
Deactivation Code:
Reactivation Date:2021-10-28
Provider Licenses
StateLicense IDTaxonomies
FLAL38612255A2300X
FLPA9115134363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer