Provider Demographics
NPI:1285106351
Name:GONZALEZ, JESSICA JEANETTE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JEANETTE
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 1:117 APACHE CIR
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-3600
Mailing Address - Country:US
Mailing Address - Phone:210-373-9613
Mailing Address - Fax:
Practice Address - Street 1:100 RANCH HOUSE RD
Practice Address - Street 2:
Practice Address - City:CIBOLO
Practice Address - State:TX
Practice Address - Zip Code:78108-4346
Practice Address - Country:US
Practice Address - Phone:702-924-2561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-29
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-16-25717103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-16-25717OtherBACB