Provider Demographics
NPI:1992985329
Name:GALLEGOS, JACKIE HELEN (LPC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:HELEN
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-3621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2147 N ACADEMY BLVD STE 3
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1507
Practice Address - Country:US
Practice Address - Phone:719-201-7953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0004671101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82139717Medicaid