Healthcare Provider Details

I. General information

NPI: 1750783999
Provider Name (Legal Business Name): JENNIFER GONZALEZ OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 LIVINGSTON LOOP STE B1
SANTA TERESA NM
88008-9747
US

IV. Provider business mailing address

103 LIVINGSTON LOOP STE B1
SANTA TERESA NM
88008-9747
US

V. Phone/Fax

Practice location:
  • Phone: 915-255-0487
  • Fax:
Mailing address:
  • Phone: 915-255-0487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number3256
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number106449
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: