Healthcare Provider Details

I. General information

NPI: 1457558900
Provider Name (Legal Business Name): JAIME GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E FOOTHILL BLVD
RIALTO CA
92376-5230
US

IV. Provider business mailing address

12625 HESPERIA RD
VICTORVILLE CA
92395-7720
US

V. Phone/Fax

Practice location:
  • Phone: 909-873-4409
  • Fax:
Mailing address:
  • Phone: 760-995-8300
  • Fax: 760-956-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: