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General NPI Number Information
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NPI Number | 1790668069
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Entity Type | Organization
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Legal Business Name | FULL SPECTRUM THERAPY
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Dates
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Enumeration Date | 07/25/2025
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Last Update Date | 07/25/2025
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Provider Practice Location Address
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Address Line | 805 N ARTHUR AVE
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City | POCATELLO
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State | ID
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Zip | 83204-2803
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Country | US
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Telephone | 208-274-5925
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Fax |
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Provider Business Mailing Address
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Address Line | 805 N ARTHUR AVE
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City | POCATELLO
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State | ID
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Zip | 83204-2803
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Country | US
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Telephone | 208-274-5925
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. JENN GALLUP
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Credential | PH.D.
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Telephone | 208-406-2492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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