Healthcare Provider Details

I. General information

NPI: 1457554164
Provider Name (Legal Business Name): JACQUELINE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9864 BALDWIN PLACE
EL MONTE CA
91731
US

IV. Provider business mailing address

23301 QUAIL SUMMIT DRIVE
DIAMOND BAR CA
91765
US

V. Phone/Fax

Practice location:
  • Phone: 626-433-1311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95160427
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number32511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: