Provider Demographics
NPI:1407670094
Name:GONZALEZ, JACKIE AGNESS
Entity type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:AGNESS
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4307 EAGLE TRACE CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3116
Mailing Address - Country:US
Mailing Address - Phone:301-351-7881
Mailing Address - Fax:
Practice Address - Street 1:4307 EAGLE TRACE CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3116
Practice Address - Country:US
Practice Address - Phone:301-351-7881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR131587363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health