Provider Demographics
NPI:1154561215
Name:DALLERY, JESSE (PHD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:DALLERY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11124 NW 38TH LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-4986
Mailing Address - Country:US
Mailing Address - Phone:352-514-9262
Mailing Address - Fax:
Practice Address - Street 1:1502 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4018
Practice Address - Country:US
Practice Address - Phone:352-332-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical