Provider Demographics
NPI:1164031142
Name:GALLARDO, JASPER ANTHONY
Entity Type:Individual
Prefix:
First Name:JASPER
Middle Name:ANTHONY
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 ORR AND DAY RD APT 9
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-3566
Mailing Address - Country:US
Mailing Address - Phone:562-325-3833
Mailing Address - Fax:
Practice Address - Street 1:10220 ORR AND DAY RD APT 9
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3566
Practice Address - Country:US
Practice Address - Phone:562-325-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3237005103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst