Provider Demographics
NPI:1154657245
Name:LARSON, JEFFREY GERARD
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:GERARD
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 DUNHAM RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1431
Mailing Address - Country:US
Mailing Address - Phone:630-444-1801
Mailing Address - Fax:630-444-0494
Practice Address - Street 1:451 DUNHAM RD
Practice Address - Street 2:SUITE 400
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1431
Practice Address - Country:US
Practice Address - Phone:630-444-1801
Practice Address - Fax:630-444-0494
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490122961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1235255993OtherNPI
IL149012296OtherIL CLINICAL SOCIAL WORKER LICENSE