Provider Demographics
NPI:1104224591
Name:GONZALEZ, JOLIE (PT)
Entity type:Individual
Prefix:
First Name:JOLIE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JOLIE
Other - Middle Name:
Other - Last Name:BREHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:40 ESTUARY CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3748
Mailing Address - Country:US
Mailing Address - Phone:808-250-3447
Mailing Address - Fax:
Practice Address - Street 1:2035 LYNDELL TER
Practice Address - Street 2:SUITE 200
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6222
Practice Address - Country:US
Practice Address - Phone:530-758-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41917225100000X
AZ10914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist