Provider Demographics
NPI:1508170432
Name:GALLANT, JASON PAUL ALAN (PHD, LP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL ALAN
Last Name:GALLANT
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-6719
Mailing Address - Country:US
Mailing Address - Phone:407-853-7700
Mailing Address - Fax:407-853-7739
Practice Address - Street 1:7001 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-6719
Practice Address - Country:US
Practice Address - Phone:407-853-7700
Practice Address - Fax:407-853-7739
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8558103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029959604Medicaid
FL029959604Medicaid