Provider Demographics
NPI:1790668069
Name:FULL SPECTRUM THERAPY
Entity type:Organization
Organization Name:FULL SPECTRUM THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLUP
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-406-2492
Mailing Address - Street 1:805 N ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-2803
Mailing Address - Country:US
Mailing Address - Phone:208-274-5925
Mailing Address - Fax:
Practice Address - Street 1:805 N ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-2803
Practice Address - Country:US
Practice Address - Phone:208-274-5925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-25
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty