Healthcare Provider Details

I. General information

NPI: 1801790811
Provider Name (Legal Business Name): JACQUELYNE GONZALEZ CCMA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 QUINCY ST
RAPID CITY SD
57701-2813
US

IV. Provider business mailing address

350 ELK ST
RAPID CITY SD
57701-7351
US

V. Phone/Fax

Practice location:
  • Phone: 605-391-4863
  • Fax: 605-343-7293
Mailing address:
  • Phone: 605-343-7262
  • Fax: 605-343-7293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: