Basic Information
| Provider Information | |||||||||
| NPI: | 1518639178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JAMIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12312 MARBEL AVE | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902422643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624194896 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23860 HAWTHORNE BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905058201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107913064 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2021 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.