Healthcare Provider Details

I. General information

NPI: 1205207057
Provider Name (Legal Business Name): JESUS GALLEGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N JOHNSON AVE
EL CAJON CA
92020-1650
US

IV. Provider business mailing address

3780 MURPHY CANYON RD 320
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 619-461-4871
  • Fax:
Mailing address:
  • Phone: 858-300-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: