Provider Demographics
NPI:1295193530
Name:HARSONO, JENNIEAN
Entity Type:Individual
Prefix:
First Name:JENNIEAN
Middle Name:
Last Name:HARSONO
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 1:427 COLONY COVE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-1437
Mailing Address - Country:US
Mailing Address - Phone:408-348-9368
Mailing Address - Fax:
Practice Address - Street 1:427 COLONY COVE DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-1437
Practice Address - Country:US
Practice Address - Phone:408-348-9368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103K00000XMedicaid