Healthcare Provider Details

I. General information

NPI: 1184282824
Provider Name (Legal Business Name): JAMIE GONZALEZ MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NE DIXIE HWY
STUART FL
34994-1872
US

IV. Provider business mailing address

1170 SW HUNNICUT AVE
PORT SAINT LUCIE FL
34953-5331
US

V. Phone/Fax

Practice location:
  • Phone: 443-975-2162
  • Fax:
Mailing address:
  • Phone:
  • 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: