Provider Demographics
NPI:1750783999
Name:GONZALEZ, JENNIFER (OTR)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 LIVINGSTON LOOP STE B1
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9747
Mailing Address - Country:US
Mailing Address - Phone:915-255-0487
Mailing Address - Fax:
Practice Address - Street 1:103 LIVINGSTON LOOP STE B1
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9747
Practice Address - Country:US
Practice Address - Phone:915-255-0487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3256225XP0019X
TX106449225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCCP036997Medicaid