Healthcare Provider Details

I. General information

NPI: 1891030656
Provider Name (Legal Business Name): MS. JEANETTE LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANETTE LARSEN MS

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7806 UPLANDS WAY
CITRUS HEIGHTS CA
95610
US

IV. Provider business mailing address

701 GIBSON DR APT 613
ROSEVILLE CA
95678-5720
US

V. Phone/Fax

Practice location:
  • Phone: 916-967-6253
  • Fax:
Mailing address:
  • Phone: 916-621-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number67510
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number111202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: