Healthcare Provider Details

I. General information

NPI: 1255175147
Provider Name (Legal Business Name): JACOB GONZALEZ MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S WALNUT ST
LAS CRUCES NM
88001-3954
US

IV. Provider business mailing address

1425 WYOMING AVE APT 4
LAS CRUCES NM
88001-5759
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-2819
  • Fax:
Mailing address:
  • Phone: 915-777-9023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: