Healthcare Provider Details

I. General information

NPI: 1326834185
Provider Name (Legal Business Name): JACOB ALLEN GONZALEZ PCT, CET, CPT, BLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 WEST AVE #113197 SMB#82886
STAMFORD CT
06911
US

IV. Provider business mailing address

317 WEST AVE #113197 SMB#82886
STAMFORD CT
06911
US

V. Phone/Fax

Practice location:
  • Phone: 203-635-3548
  • Fax:
Mailing address:
  • Phone: 203-635-3548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License NumberELECTROCARDIOGRAM
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: