Healthcare Provider Details

I. General information

NPI: 1073220208
Provider Name (Legal Business Name): JISANDRY GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 L ST NW
WASHINGTON DC
20037-1527
US

IV. Provider business mailing address

850 QUINCY ST NW APT 523
WASHINGTON DC
20011-5869
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-2900
  • Fax:
Mailing address:
  • Phone: 202-696-2785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: