Provider Demographics
NPI:1487860912
Name:LARSEN, JARED MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MICHAEL
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 HIGHWAY 36 W
Mailing Address - Street 2:400
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4034
Mailing Address - Country:US
Mailing Address - Phone:651-636-0055
Mailing Address - Fax:
Practice Address - Street 1:1700 HIGHWAY 36 W
Practice Address - Street 2:400
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4034
Practice Address - Country:US
Practice Address - Phone:651-636-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4893111N00000X
MNN204133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133N00000XDietary & Nutritional Service ProvidersNutritionist