Provider Demographics
NPI:1225428295
Name:GILLEY, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GILLEY
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:PSC 851
Mailing Address - Street 2:BOX 34008
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09834-0341
Mailing Address - Country:US
Mailing Address - Phone:318-439-9454
Mailing Address - Fax:
Practice Address - Street 1:PSC 851 BOX 340
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09834-0004
Practice Address - Country:US
Practice Address - Phone:318-439-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD184491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical