Healthcare Provider Details

I. General information

NPI: 1285983650
Provider Name (Legal Business Name): JENNIFER GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 KETTNER BLVD
SAN DIEGO CA
92101
US

IV. Provider business mailing address

2535 KETTNER BLVD
SAN DIEGO CA
92101
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0701
  • Fax:
Mailing address:
  • Phone: 619-615-0701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: