Provider Demographics
NPI:1962119289
Name:GONZALEZ, JESUS MANUEL (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:JESUS
Middle Name:MANUEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2344
Mailing Address - Country:US
Mailing Address - Phone:407-846-0023
Mailing Address - Fax:
Practice Address - Street 1:206 PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2344
Practice Address - Country:US
Practice Address - Phone:407-846-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11022204363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health