Basic Information
| Provider Information | |||||||||
| NPI: | 1770761108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | ALBINTO | ||||||||
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| OtherLastName: | ALBINTO | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | PONLA | ||||||||
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| OtherCredential: | OTRL | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1301 E BIDWELL STREET | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | 9169835932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1319 N MADISON ST | ||||||||
| Address2: | PLYMOUTH SQUARE | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094664341 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 02/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT7833 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.