Provider Demographics
NPI:1417619099
Name:GALLAGHER, JACQUELINE HELEN (OTD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:HELEN
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3846 N DESERT OASIS CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-6926
Mailing Address - Country:US
Mailing Address - Phone:817-793-7896
Mailing Address - Fax:
Practice Address - Street 1:3846 N DESERT OASIS CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-6926
Practice Address - Country:US
Practice Address - Phone:817-793-7896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics