Provider Demographics
NPI:1326638149
Name:LARSEN, JACKSON TYLER
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:TYLER
Last Name:LARSEN
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 1:785 E 550 N
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1208
Mailing Address - Country:US
Mailing Address - Phone:435-851-7427
Mailing Address - Fax:801-935-4946
Practice Address - Street 1:515 S 700 E STE 2A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2855
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician