Provider Demographics
NPI:1316787112
Name:GONZALEZ-ORTIZ, JAZZLYN MAYA
Entity type:Individual
Prefix:
First Name:JAZZLYN
Middle Name:MAYA
Last Name:GONZALEZ-ORTIZ
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 1:827 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3701
Mailing Address - Country:US
Mailing Address - Phone:909-414-4150
Mailing Address - Fax:
Practice Address - Street 1:4916 S CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6822
Practice Address - Country:US
Practice Address - Phone:619-399-9906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician