Basic Information
Provider Information | |||||||||
NPI: | 1427110816 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIREGOLO | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: | AUGUSTINE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DIREGOLO | ||||||||
OtherFirstName: | JEROLD | ||||||||
OtherMiddleName: | AUGUSTINE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1600 EUREKA RD | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956613027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167717610 | ||||||||
FaxNumber: | 9167717650 | ||||||||
Practice Location | |||||||||
Address1: | 1600 EUREKA RD | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956613027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167717610 | ||||||||
FaxNumber: | 9167717650 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY4274 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | PSY4274 | CA | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.