Provider Demographics
NPI:1699570507
Name:INCE-GALLOWAY, JAMAICA
Entity type:Individual
Prefix:
First Name:JAMAICA
Middle Name:
Last Name:INCE-GALLOWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3621
Mailing Address - Country:US
Mailing Address - Phone:707-387-2277
Mailing Address - Fax:
Practice Address - Street 1:1400 N DUTTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-7120
Practice Address - Country:US
Practice Address - Phone:707-523-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53906225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant