Healthcare Provider Details

I. General information

NPI: 1902558034
Provider Name (Legal Business Name): JESSICA C REYNA-GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MCHENRY VILLAGE WAY
MODESTO CA
95350-4308
US

IV. Provider business mailing address

3204 SMOKEHOUSE AVE
MODESTO CA
95356-0137
US

V. Phone/Fax

Practice location:
  • Phone: 209-312-9580
  • Fax:
Mailing address:
  • Phone: 209-552-5427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: