Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003087305 |
---|---|
Provider Name | Jessie Jr. N/a Galloway |
First Address | Gardena, CA 90248-3523 |
Second Address | Gardena, CA 90248-3523 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2008 |
Last Update Date | 14/03/2008 |