Healthcare Provider Details

I. General information

NPI: 1427768076
Provider Name (Legal Business Name): JESUS GAMBOA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 W. HOLLAND AVE.
FRESNO CA
93726-9372
US

IV. Provider business mailing address

3520 E SHIELDS AVE STE 102
FRESNO CA
93726-6923
US

V. Phone/Fax

Practice location:
  • Phone: 559-538-1230
  • Fax:
Mailing address:
  • Phone: 559-538-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: