Healthcare Provider Details

I. General information

NPI: 1598019838
Provider Name (Legal Business Name): JAYMES GONZALES PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 05/18/2023
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 INNOVATION DR
SAINT CLOUD FL
34769-6501
US

IV. Provider business mailing address

3115 INNOVATION DR
SAINT CLOUD FL
34769-6501
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-7304
  • Fax:
Mailing address:
  • Phone: 407-892-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043323B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: