Provider Demographics
NPI:1427110816
Name:DIREGOLO, JERRY AUGUSTINE (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:AUGUSTINE
Last Name:DIREGOLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JEROLD
Other - Middle Name:AUGUSTINE
Other - Last Name:DIREGOLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1600 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3027
Mailing Address - Country:US
Mailing Address - Phone:916-771-7610
Mailing Address - Fax:916-771-7650
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-771-7610
Practice Address - Fax:916-771-7650
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4274103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent