Provider Demographics
NPI:1487381471
Name:NGALLE, JERRY E
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:E
Last Name:NGALLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 E FORGE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-4916
Mailing Address - Country:US
Mailing Address - Phone:602-775-0609
Mailing Address - Fax:
Practice Address - Street 1:721 E FORGE AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-4916
Practice Address - Country:US
Practice Address - Phone:602-775-0609
Practice Address - Fax:480-687-5301
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-10-04
Deactivation Date:2022-09-27
Deactivation Code:
Reactivation Date:2022-10-04
Provider Licenses
StateLicense IDTaxonomies
103K00000X
AZ374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst