MEDICARE: JESSICA GONZALES LSW

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	1041C0700X	Clinical Social Worker	0009925104	CO

General Provider Information

NPI Number	:	1992587091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GONZALES LSW

Provider Business Mailing Address
First Line	:	10139 LODESTONE WAY
Second Line	:
City	:	PARKER
State	:	CO
Zip	:	80134-9532
Country	:	US
Telephone Number	:	717-419-0373
Fax Number	:

Provider Business Practice Location Address
First Line	:	19590 E MAINSTREET STE 100-5
Second Line	:
City	:	PARKER
State	:	CO
Zip	:	80138-7302
Country	:	US
Telephone Number	:	720-740-3510
Fax Number	:

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

Provider Enumeration Date	:	10/16/2023
Last Update Date	:	08/12/2024

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