Provider Demographics
NPI:1548001696
Name:GONZALEZ, JENNIFER DE GUADALUPE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DE GUADALUPE
Last Name: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 1:4461 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2558
Mailing Address - Country:US
Mailing Address - Phone:786-874-8777
Mailing Address - Fax:
Practice Address - Street 1:4461 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33134-2558
Practice Address - Country:US
Practice Address - Phone:786-874-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-338950106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty