Provider Demographics
NPI:1902230998
Name:GALLEGOS, JENNA RAQUEL (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:RAQUEL
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 VISTA DEL NORTE RD NE
Mailing Address - Street 2:APT. 1312
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1311
Mailing Address - Country:US
Mailing Address - Phone:505-270-4585
Mailing Address - Fax:
Practice Address - Street 1:8500 WASHINGTON ST NE
Practice Address - Street 2:SUITE A-1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1846
Practice Address - Country:US
Practice Address - Phone:505-828-3837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-13-13791103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst