Provider Demographics
NPI:1114029535
Name:GALLAGHER, JENNIFER MARIE (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:DE BLASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:225 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4249
Mailing Address - Country:US
Mailing Address - Phone:760-291-6700
Mailing Address - Fax:
Practice Address - Street 1:225 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4249
Practice Address - Country:US
Practice Address - Phone:760-291-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000396363A00000X
CAPA 21721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21721OtherCA PA LICENSE