Provider Demographics
NPI:1073094215
Name:LARGO, JENNYROSE DIANE
Entity Type:Individual
Prefix:
First Name:JENNYROSE
Middle Name:DIANE
Last Name:LARGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:594 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1950
Mailing Address - Country:US
Mailing Address - Phone:650-892-9944
Mailing Address - Fax:
Practice Address - Street 1:594 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1950
Practice Address - Country:US
Practice Address - Phone:650-892-9944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA621642728Medicaid