Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003302902 |
---|---|
Provider Name | Jaycob Gonzales-Cordova |
First Address | Pueblo, CO 81001-1366 |
Second Address | Pueblo, CO 81001-1851 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2018 |
Last Update Date | 03/07/2018 |