Healthcare Provider Details

I. General information

NPI: 1699289892
Provider Name (Legal Business Name): JESSICA RAE GALLEGOS CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 06/26/2022
Certification Date: 06/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N SANTA ROSA
SAN ANTONIO TX
78207-3108
US

IV. Provider business mailing address

315 N SAN SABA STE 1135
SAN ANTONIO TX
78207-3255
US

V. Phone/Fax

Practice location:
  • Phone: 210-704-2011
  • Fax:
Mailing address:
  • Phone: 210-704-3030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number827370
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberAP135893
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: