Provider Demographics
NPI:1013199389
Name:GALLEGOS-JACKSON, ELISA (RN, PHN)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:GALLEGOS-JACKSON
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 CENTER ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1169
Mailing Address - Country:US
Mailing Address - Phone:510-981-7684
Mailing Address - Fax:510-981-5345
Practice Address - Street 1:1947 CENTER ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1169
Practice Address - Country:US
Practice Address - Phone:510-981-7684
Practice Address - Fax:510-981-5345
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN493217163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse