Provider Demographics
NPI:1215597372
Name:LARSON, JESSE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12531 REGENCY PKWY
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-6500
Mailing Address - Country:US
Mailing Address - Phone:847-659-1000
Mailing Address - Fax:847-659-1012
Practice Address - Street 1:9551 ACKMAN RD
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-9709
Practice Address - Country:US
Practice Address - Phone:847-669-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist