Provider Demographics
NPI:1851264006
Name:GONZALES, GJENIKWA D
Entity type:Individual
Prefix:MRS
First Name:GJENIKWA
Middle Name:D
Last Name:GONZALES
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 1:1407 PROSPECT AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1707
Mailing Address - Country:US
Mailing Address - Phone:616-217-7679
Mailing Address - Fax:
Practice Address - Street 1:1407 PROSPECT AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1707
Practice Address - Country:US
Practice Address - Phone:616-217-7679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty