Provider Demographics
NPI:1942569769
Name:GALLIGAN, JENNIFER (LMP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:GALLIGAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26706 262ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:RAVENSDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98051-9520
Mailing Address - Country:US
Mailing Address - Phone:949-510-4526
Mailing Address - Fax:
Practice Address - Street 1:26706 262ND AVE SE
Practice Address - Street 2:
Practice Address - City:RAVENSDALE
Practice Address - State:WA
Practice Address - Zip Code:98051-9520
Practice Address - Country:US
Practice Address - Phone:949-510-4526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60263232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist