Provider Demographics
NPI:1891030656
Name:LARSEN, JEANETTE
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JEANETTE
Other - Middle Name:
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:701 GIBSON DR APT 613
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5720
Mailing Address - Country:US
Mailing Address - Phone:916-621-7006
Mailing Address - Fax:
Practice Address - Street 1:7806 UPLANDS WAY
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610
Practice Address - Country:US
Practice Address - Phone:916-967-6253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67510106H00000X
101Y00000X
CA111202106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor