=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699570507
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMAICA INCE-GALLOWAY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2025
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 N DUTTON AVE STE 1
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-7120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-523-2848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 S WASHINGTON ST
-----------------------------------------------------
City | CLOVERDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95425-3621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-387-2277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 53906
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------