Provider Demographics
NPI:1033441308
Name:LARSEN, JEFFERY BLYTHE (PHD, CCC-A)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:BLYTHE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PHD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6410
Mailing Address - Country:US
Mailing Address - Phone:435-797-1373
Mailing Address - Fax:844-308-5865
Practice Address - Street 1:1000 OLD MAIN HL
Practice Address - Street 2:COMD DEPARTMENT, UMC 1000
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-1000
Practice Address - Country:US
Practice Address - Phone:435-797-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6207896-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist