Provider Demographics
NPI:1306191325
Name:LARSON, JILL KRISTINE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:KRISTINE
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:KRISTINE
Other - Last Name:SWENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 WOODDALE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4441
Mailing Address - Country:US
Mailing Address - Phone:651-738-9888
Mailing Address - Fax:651-738-9889
Practice Address - Street 1:2101 WOODDALE DR
Practice Address - Street 2:SUITE A
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4441
Practice Address - Country:US
Practice Address - Phone:651-738-9888
Practice Address - Fax:651-738-9889
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist