Provider Demographics
NPI:1437657376
Name:GALLAHER, JASON E (LPCC, LMT,)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:E
Last Name:GALLAHER
Suffix:
Gender:M
Credentials:LPCC, LMT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 PEARL PKWY APT 112
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2412
Mailing Address - Country:US
Mailing Address - Phone:419-351-2824
Mailing Address - Fax:
Practice Address - Street 1:2945 CENTER GREEN CT STE H
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2275
Practice Address - Country:US
Practice Address - Phone:419-351-2824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0015846101Y00000X
COMT.0020930225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO$$$$$$$$$Medicaid