Provider Demographics
NPI:1508041807
Name:LARSON, JENNIFER (MA, LCPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5142 N LEAVITT ST
Mailing Address - Street 2:STE 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6829
Mailing Address - Country:US
Mailing Address - Phone:773-398-0359
Mailing Address - Fax:773-989-7207
Practice Address - Street 1:25 E WASHINGTON ST STE 1406
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1820
Practice Address - Country:US
Practice Address - Phone:773-398-0359
Practice Address - Fax:773-989-7207
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-04
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006534101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01638687OtherBCBS