MEDICARE: JANE ELLEN HARGRAVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	42877	CA

General Provider Information

NPI Number	:	1053179564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE ELLEN HARGRAVE

Provider Business Mailing Address
First Line	:	1558 JAMES AVE
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94062-2249
Country	:	US
Telephone Number	:	650-207-4864
Fax Number	:

Provider Business Practice Location Address
First Line	:	1558 JAMES AVE
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94062-2249
Country	:	US
Telephone Number	:	510-859-7835
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2024
Last Update Date	:	03/08/2024

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