Provider Demographics
NPI:1508878935
Name:WHITE, JEANETTE R
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:R
Last Name:WHITE
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 1:5 BON AIR ROAD, STE. 105
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939
Mailing Address - Country:US
Mailing Address - Phone:415-461-0440
Mailing Address - Fax:415-461-3792
Practice Address - Street 1:5 BON AIR ROAD, STE. 105
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939
Practice Address - Country:US
Practice Address - Phone:415-461-0440
Practice Address - Fax:415-461-3792
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD554712080P0203X
CAC54743208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD945300801Medicaid
MD141678ZAKHMedicare PIN
G39268Medicare UPIN