Healthcare Provider Details

I. General information

NPI: 1356190193
Provider Name (Legal Business Name): JASON B LARICK PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W ROUTE 66 STE 202
GLENDORA CA
91740-4335
US

IV. Provider business mailing address

415 W ROUTE 66 STE 202
GLENDORA CA
91740-4335
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-4467
  • Fax:
Mailing address:
  • Phone: 626-963-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95030298
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number663326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: