Healthcare Provider Details

I. General information

NPI: 1154051175
Provider Name (Legal Business Name): MARJOLYE JAEN GONZALEZ PERALTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CONCORD AVE STE 185
CONCORD CA
94520-5006
US

IV. Provider business mailing address

1200 CONCORD AVE STE 185
CONCORD CA
94520-5006
US

V. Phone/Fax

Practice location:
  • Phone: 510-268-8120
  • Fax:
Mailing address:
  • Phone: 831-524-9068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-87333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: