Provider Demographics
NPI:1285251504
Name:GONZALEZ, JORGE MARIO JR
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:MARIO
Last Name:GONZALEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3917
Mailing Address - Country:US
Mailing Address - Phone:415-229-0500
Mailing Address - Fax:415-647-0740
Practice Address - Street 1:250 EXECUTIVE PARK BLVD STE 4900
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-3335
Practice Address - Country:US
Practice Address - Phone:415-656-0116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 390200000X, 106H00000X
CA172V00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CVILLACREZOtherCCR