Healthcare Provider Details

I. General information

NPI: 1245963651
Provider Name (Legal Business Name): JARED J. GONZALES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2022
Last Update Date: 07/04/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 MISSOURI AVE
LAS CRUCES NM
88001-5327
US

IV. Provider business mailing address

4672 MESITA ST
LAS CRUCES NM
88012-6329
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5466
  • Fax:
Mailing address:
  • Phone: 575-621-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JARED GONZALES
Title or Position: PSYCHOLOGIST
Credential: PH. D.
Phone: 575-621-4304