Healthcare Provider Details

I. General information

NPI: 1801224332
Provider Name (Legal Business Name): DR. JARED GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2013
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
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: 575-621-4304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number313091
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1734
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: