Basic Information
| Provider Information | |||||||||
| NPI: | 1891030656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARSEN | ||||||||
| OtherFirstName: | JEANETTE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 GIBSON DR APT 613 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956785720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166217006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7806 UPLANDS WAY | ||||||||
| Address2: | |||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169676253 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2012 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 67510 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 111202 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.