Provider Demographics
NPI:1952923955
Name:LARREINAGA, JESSICA (CO60972165)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LARREINAGA
Suffix:
Gender:F
Credentials:CO60972165
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-2702
Mailing Address - Country:US
Mailing Address - Phone:253-590-9549
Mailing Address - Fax:
Practice Address - Street 1:4928 109TH ST SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3731
Practice Address - Country:US
Practice Address - Phone:253-473-7474
Practice Address - Fax:253-474-9724
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO609720165101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)