Provider Demographics
NPI:1477866762
Name:LARSON, JENNIFER RAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 CAHILL MAIN
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-7109
Mailing Address - Country:US
Mailing Address - Phone:608-661-7220
Mailing Address - Fax:
Practice Address - Street 1:702 EAGLE HTS
Practice Address - Street 2:APT. C
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-1587
Practice Address - Country:US
Practice Address - Phone:608-692-2785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15980-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15890-040OtherSTATE OF WISCONSIN