Provider Demographics
NPI:1972286565
Name:GALLIK, JACQUELINE BROOKE (MS OTR/L)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BROOKE
Last Name:GALLIK
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2223
Mailing Address - Country:US
Mailing Address - Phone:570-352-5155
Mailing Address - Fax:
Practice Address - Street 1:601 PARK ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1498
Practice Address - Country:US
Practice Address - Phone:570-253-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC017109225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist