Provider Demographics
NPI:1861268104
Name:GONGORA, JENIFFER
Entity type:Individual
Prefix:
First Name:JENIFFER
Middle Name:
Last Name:GONGORA
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 1:6451 SW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1919
Mailing Address - Country:US
Mailing Address - Phone:786-498-2924
Mailing Address - Fax:
Practice Address - Street 1:6451 SW 19TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1919
Practice Address - Country:US
Practice Address - Phone:786-498-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician