Provider Demographics
NPI:1073966461
Name:GALLIOS, JACQUELINE M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:M
Last Name:GALLIOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 POMPTON AVENUE
Mailing Address - Street 2:SUITE #106
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1720
Mailing Address - Country:US
Mailing Address - Phone:201-647-9199
Mailing Address - Fax:
Practice Address - Street 1:579 POMPTON AVENUE
Practice Address - Street 2:SUITE #106
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1720
Practice Address - Country:US
Practice Address - Phone:201-647-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00578100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical