Basic Information
| Provider Information | |||||||||
| NPI: | 1285251504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | MARIO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2919 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152290500 | ||||||||
| FaxNumber: | 4156470740 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 EXECUTIVE PARK BLVD STE 4900 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941343335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156560116 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2020 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 172V00000X | CA | N | Other Service Providers | Community Health Worker | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | CVILLACREZ | 01 | CCR | OTHER |