Provider Demographics
NPI:1467675223
Name:GILLOOLY, JESSICA BARRON (MFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BARRON
Last Name:GILLOOLY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 S SAINT JOHN AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2914
Mailing Address - Country:US
Mailing Address - Phone:626-403-6555
Mailing Address - Fax:626-403-6556
Practice Address - Street 1:628 S SAINT JOHN AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2914
Practice Address - Country:US
Practice Address - Phone:626-403-6555
Practice Address - Fax:626-403-6556
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM13460106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist