Provider Demographics
NPI:1184675233
Name:LARSON, JENNIFER (ARNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 BROOKS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7338
Mailing Address - Country:US
Mailing Address - Phone:888-227-3312
Mailing Address - Fax:
Practice Address - Street 1:3624 BROOKS ST STE 101
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7338
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6338207V00000X
WAAP61059800363LF0000X
MT100183363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4303788Medicaid
MT000374300OtherBLUE CROSS BLUE SHIELD
MT000374300OtherBLUE CROSS BLUE SHIELD