Healthcare Provider Details

I. General information

NPI: 1902362312
Provider Name (Legal Business Name): JAMIE ALEXANDER GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 W COMMONWEALTH AVE STE C
FULLERTON CA
92832-1612
US

IV. Provider business mailing address

233 ORANGEFAIR MALL
FULLERTON CA
92832-3038
US

V. Phone/Fax

Practice location:
  • Phone: 714-879-4274
  • Fax: 714-879-4274
Mailing address:
  • Phone: 714-870-6116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number24288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: