Provider Demographics
NPI:1447376553
Name:GONZAGA, JACQUELINE
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:
Last Name:GONZAGA
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 1:14410 S LIME AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-2519
Mailing Address - Country:US
Mailing Address - Phone:310-635-4712
Mailing Address - Fax:
Practice Address - Street 1:1855 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1620
Practice Address - Country:US
Practice Address - Phone:626-296-7710
Practice Address - Fax:626-296-7714
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225400000XOtherMHW