Provider Demographics
NPI:1083068480
Name:LARSEN, JESSICA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 9TH ST APT 511
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2187
Mailing Address - Country:US
Mailing Address - Phone:646-498-0997
Mailing Address - Fax:
Practice Address - Street 1:501 9TH ST APT 511
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-2187
Practice Address - Country:US
Practice Address - Phone:646-498-0997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1261103TC0700X
NJ5659103TC0700X
NY21856103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical