Provider Demographics
NPI:1497463202
Name:LARSON, JENEE
Entity Type:Individual
Prefix:
First Name:JENEE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-8717
Mailing Address - Country:US
Mailing Address - Phone:715-600-3432
Mailing Address - Fax:
Practice Address - Street 1:221 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:WI
Practice Address - Zip Code:54822-8717
Practice Address - Country:US
Practice Address - Phone:715-600-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician