Provider Demographics
NPI:1285413658
Name:GONZALEZ, JALISA ANNELIS
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:ANNELIS
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JALISA
Other - Middle Name:ANNELIS
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29630 MORNING BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8434
Mailing Address - Country:US
Mailing Address - Phone:951-623-3771
Mailing Address - Fax:
Practice Address - Street 1:11799 SEBASTIAN WAY STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0708
Practice Address - Country:US
Practice Address - Phone:800-465-3203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician