Healthcare Provider Details

I. General information

NPI: 1114054665
Provider Name (Legal Business Name): JANNELLE ANNETTE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S DE LACEY AVE SUITE 110
PASADENA CA
91105-2048
US

IV. Provider business mailing address

2245 E COLORADO BLVD #104 PM331
PASADENA CA
91107-3682
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-824-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: