Provider Demographics
NPI:1386479426
Name:BASS-GONZALEZ, JENNIFER DARLENE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DARLENE
Last Name:BASS-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 1:24801 RAINEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MC KENNEY
Mailing Address - State:VA
Mailing Address - Zip Code:23872-2315
Mailing Address - Country:US
Mailing Address - Phone:434-294-7305
Mailing Address - Fax:
Practice Address - Street 1:24801 RAINEY CREEK RD
Practice Address - Street 2:
Practice Address - City:MC KENNEY
Practice Address - State:VA
Practice Address - Zip Code:23872-2315
Practice Address - Country:US
Practice Address - Phone:434-294-7305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool