Provider Demographics
NPI:1194382028
Name:GALLI, JENNA NICOL
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOL
Last Name:GALLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 KING ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3127
Mailing Address - Country:US
Mailing Address - Phone:914-618-1787
Mailing Address - Fax:
Practice Address - Street 1:156 KING ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3127
Practice Address - Country:US
Practice Address - Phone:914-618-1787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2023-02-11
Deactivation Date:2020-08-29
Deactivation Code:
Reactivation Date:2023-02-11
Provider Licenses
StateLicense IDTaxonomies
NY1273629181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist