Healthcare Provider Details

I. General information

NPI: 1255972626
Provider Name (Legal Business Name): JAQUELYN RENEE GONZALEZ MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAQUELYN RENEE PAIGE

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 SAN JERONIMO DR
ANCHORAGE AK
99508-2870
US

IV. Provider business mailing address

3600 SAN JERONIMO DR
ANCHORAGE AK
99508-2870
US

V. Phone/Fax

Practice location:
  • Phone: 907-793-3241
  • Fax:
Mailing address:
  • Phone: 907-793-3241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: