Provider Demographics
NPI:1720608839
Name:PERCIVALLE, JARRETT ANTONIO
Entity Type:Individual
Prefix:
First Name:JARRETT
Middle Name:ANTONIO
Last Name:PERCIVALLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-6819
Mailing Address - Country:US
Mailing Address - Phone:925-548-5847
Mailing Address - Fax:
Practice Address - Street 1:1515 GROVE WAY
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-6819
Practice Address - Country:US
Practice Address - Phone:925-548-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician