Healthcare Provider Details

I. General information

NPI: 1972081362
Provider Name (Legal Business Name): JENNIFER ANN GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 GAUSE BLVD STE 201
SLIDELL LA
70458-2853
US

IV. Provider business mailing address

700 GAUSE BLVD STE 201
SLIDELL LA
70458-2853
US

V. Phone/Fax

Practice location:
  • Phone: 985-326-8501
  • Fax: 985-326-8503
Mailing address:
  • Phone: 985-326-8501
  • Fax: 985-326-8503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number20100519
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: