Provider Demographics
NPI:1548995855
Name:GALLAGHER, JESSICA (RBT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 GRAHAM RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-1562
Mailing Address - Country:US
Mailing Address - Phone:203-206-8119
Mailing Address - Fax:
Practice Address - Street 1:98 S TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4340
Practice Address - Country:US
Practice Address - Phone:860-440-7288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTBACB691969106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician