Healthcare Provider Details

I. General information

NPI: 1477806040
Provider Name (Legal Business Name): JESSIE EVELYN GONZALEZ MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1831
US

IV. Provider business mailing address

711 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1831
US

V. Phone/Fax

Practice location:
  • Phone: 323-385-5100
  • Fax: 213-807-1995
Mailing address:
  • Phone: 323-385-5100
  • Fax: 213-807-1995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: