Provider Demographics
NPI:1154643310
Name:LARSON, JENELLE D (LMFT)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:D
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5417 JAMES PL SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-3855
Mailing Address - Country:US
Mailing Address - Phone:805-331-0867
Mailing Address - Fax:
Practice Address - Street 1:816 F ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6121
Practice Address - Country:US
Practice Address - Phone:253-939-2202
Practice Address - Fax:253-735-1894
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF 60194305106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist