Provider Demographics
NPI:1487665584
Name:LARSON, JENNIFER REBEKAH (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBEKAH
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:REBEKAH
Other - Last Name:HIEMENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:8406 SIX FORKS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3075
Mailing Address - Country:US
Mailing Address - Phone:919-473-6451
Mailing Address - Fax:844-584-4207
Practice Address - Street 1:8406 SIX FORKS RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3075
Practice Address - Country:US
Practice Address - Phone:919-473-6451
Practice Address - Fax:844-584-4207
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2648103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC045GAOtherBCBS
NC6000216Medicaid
NC2819880Medicare UPIN