MEDICARE: JESSICA GONZALEZ

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1821427089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GONZALEZ

Provider Business Mailing Address
First Line	:	12522 GOTHAM DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77089-6111
Country	:	US
Telephone Number	:	832-573-7701
Fax Number	:

Provider Business Practice Location Address
First Line	:	12522 GOTHAM DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77089-6111
Country	:	US
Telephone Number	:	832-573-7701
Fax Number	:

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

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	02/18/2014

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