Provider Demographics
NPI:1467022590
Name:LARSON, JESSICA (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 ROCK ST APT 105
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-4395
Mailing Address - Country:US
Mailing Address - Phone:501-762-7910
Mailing Address - Fax:
Practice Address - Street 1:4189 PHOENIX AVE STE B
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6013
Practice Address - Country:US
Practice Address - Phone:479-434-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2828152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist