Provider Demographics
NPI:1609648807
Name:GALLUP, JENNIFER LESLIE (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LESLIE
Last Name:GALLUP
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6341
Mailing Address - Country:US
Mailing Address - Phone:208-406-2492
Mailing Address - Fax:
Practice Address - Street 1:427 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6341
Practice Address - Country:US
Practice Address - Phone:208-274-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
ID203485103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist