Healthcare Provider Details

I. General information

NPI: 1558156877
Provider Name (Legal Business Name): JACK O'MALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 WILLAMETTE DR NE STE A
LACEY WA
98516-1378
US

IV. Provider business mailing address

3231 WILLAMETTE DR NE STE A
LACEY WA
98516-1378
US

V. Phone/Fax

Practice location:
  • Phone: 360-878-6434
  • Fax:
Mailing address:
  • Phone: 360-878-6434
  • Fax: 844-452-1758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA.BA.70165803
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: