Basic Information
| Provider Information | |||||||||
| NPI: | 1316372329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | MARKOS | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 YALE BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871063825 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 YALE BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871063825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052720053 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 10622 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.