Healthcare Provider Details

I. General information

NPI: 1972816122
Provider Name (Legal Business Name): JENNIFER GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13222 FARADAY DR DR
HOUSTON TX
77047-3229
US

IV. Provider business mailing address

13222 FARADAY DR
HOUSTON TX
77047
US

V. Phone/Fax

Practice location:
  • Phone: 832-309-6764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number107625
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: