Healthcare Provider Details

I. General information

NPI: 1376862037
Provider Name (Legal Business Name): JAIME GONZALEZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98531
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CENTER JOINT BASE LEWIS-MCCHORD
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-4849
  • Fax: 253-968-3731
Mailing address:
  • Phone: 253-968-4849
  • Fax: 253-968-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP5426
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60778412
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: