MEDICARE: DR. JAIME GONZALEZ PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY60778412	WA
2	103T00000X	Psychologist	LP5426	MN

General Provider Information

NPI Number	:	1376862037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAIME GONZALEZ PH.D.

Provider Business Mailing Address
First Line	:	MADIGAN ARMY MEDICAL CENTER JOINT BASE LEWIS-MCCHORD
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98431-1100
Country	:	US
Telephone Number	:	253-968-4849
Fax Number	:	253-968-3731

Provider Business Practice Location Address
First Line	:	MADIGAN ARMY MEDICAL CENTER
Second Line	:	9040 JACKSON AVE
City	:	TACOMA
State	:	WA
Zip	:	98531
Country	:	US
Telephone Number	:	253-968-4849
Fax Number	:	253-968-3731

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2010
Last Update Date	:	02/21/2019

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