Provider Demographics
NPI:1154519239
Name:GONZALEZ, JENNIFER W (PA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:W
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2640
Mailing Address - Country:US
Mailing Address - Phone:937-245-7200
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:725 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45324-2640
Practice Address - Country:US
Practice Address - Phone:937-245-7200
Practice Address - Fax:937-245-7999
Is Sole Proprietor?:No
Enumeration Date:2007-10-14
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112057363A00000X
OH50.007105RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104159800Medicaid
OH0462499Medicaid
FL0EJPXOtherBLUE CROSS BLUE SHIELD
SC5551OtherMEDICARE GROUP #
SCGP4832OtherMEDICAID GROUP #
1069446OtherNCCPA
SC0578PAMedicaid