Provider Demographics
NPI:1902558034
Name:REYNA-GONZALEZ, JESSICA C
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:REYNA-GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 SMOKEHOUSE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-0137
Mailing Address - Country:US
Mailing Address - Phone:209-552-5427
Mailing Address - Fax:
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4308
Practice Address - Country:US
Practice Address - Phone:209-312-9580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker