Healthcare Provider Details

I. General information

NPI: 1669156410
Provider Name (Legal Business Name): JACK GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E FOOTHILL BLVD STE 105
ARCADIA CA
91006-2335
US

IV. Provider business mailing address

PO BOX 740780
ATLANTA GA
30374-0780
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax: 619-374-7134
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-374676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: