Provider Demographics
NPI:1013288364
Name:GALLI ROBERTSON, JESSICA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:GALLI ROBERTSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3191
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:30 E APPLE ST STE 5254A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-208-4200
Practice Address - Fax:937-208-4205
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005506RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1102906OtherNCCPA
MDC0004672OtherMARYLAND BOARD OF PHYSICIANS