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General NPI Number Information
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NPI Number | 1659133411
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Entity Type | Individual
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Provider Name | JESSE RAY GONZALES
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Gender | Male
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Dates
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Enumeration Date | 01/26/2024
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Last Update Date | 01/26/2024
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Provider Practice Location Address
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Address Line | 12100 WILSHIRE BLVD STE 836
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City | LOS ANGELES
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State | CA
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Zip | 90025-7120
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Country | US
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Telephone | 516-590-7575
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Fax |
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Provider Business Mailing Address
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Address Line | 14675 NORFOLK AVE
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City | CHINO
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State | CA
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Zip | 91710-1361
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Country | US
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Telephone | 909-248-5300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 1056065
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License Number State | CA
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