Healthcare Provider Details

I. General information

NPI: 1356654347
Provider Name (Legal Business Name): JARY LARSEN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUIR RD RESEARCH SERVICE (151)
MARTINEZ CA
94553-4668
US

IV. Provider business mailing address

150 MUIR RD RESEARCH SERVICE (151)
MARTINEZ CA
94553-4668
US

V. Phone/Fax

Practice location:
  • Phone: 925-370-4083
  • Fax: 925-228-5738
Mailing address:
  • Phone: 925-370-4083
  • Fax: 925-228-5738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY15816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: