Healthcare Provider Details

I. General information

NPI: 1235914656
Provider Name (Legal Business Name): JESSICA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3354 HIGHWAY 160
INDEPENDENCE KS
67301-7841
US

IV. Provider business mailing address

2121 SW CHELSEA DR
TOPEKA KS
66614-1756
US

V. Phone/Fax

Practice location:
  • Phone: 620-331-3131
  • Fax: 620-332-5110
Mailing address:
  • Phone: 785-291-9644
  • Fax: 888-977-1591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number01740
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: