Healthcare Provider Details

I. General information

NPI: 1639052517
Provider Name (Legal Business Name): JESSICA JEWETTE GONZALEZ LCDC-I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 MASON PARK BLVD
KATY TX
77450-6241
US

IV. Provider business mailing address

10926 SPANISH GRANT DR
SUGAR LAND TX
77498-1762
US

V. Phone/Fax

Practice location:
  • Phone: 800-685-9796
  • Fax:
Mailing address:
  • Phone: 281-925-8642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number72693
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: