Healthcare Provider Details

I. General information

NPI: 1790668069
Provider Name (Legal Business Name): FULL SPECTRUM THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N ARTHUR AVE
POCATELLO ID
83204-2803
US

IV. Provider business mailing address

805 N ARTHUR AVE
POCATELLO ID
83204-2803
US

V. Phone/Fax

Practice location:
  • Phone: 208-274-5925
  • Fax:
Mailing address:
  • Phone: 208-274-5925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JENN GALLUP
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 208-406-2492