Provider Demographics
NPI:1306555248
Name:CROSSETT, JENEVIEVE MARIE
Entity type:Individual
Prefix:
First Name:JENEVIEVE
Middle Name:MARIE
Last Name:CROSSETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RIVER RD SPC 1
Mailing Address - Street 2:
Mailing Address - City:SAN MIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:93451-9516
Mailing Address - Country:US
Mailing Address - Phone:805-769-7216
Mailing Address - Fax:
Practice Address - Street 1:1212 MARSH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3346
Practice Address - Country:US
Practice Address - Phone:818-345-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician