Provider Demographics
NPI:1528412244
Name:LARSON, JESSE D (DPM)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:D
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-5326
Mailing Address - Country:US
Mailing Address - Phone:805-209-4400
Mailing Address - Fax:
Practice Address - Street 1:71 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-5326
Practice Address - Country:US
Practice Address - Phone:805-209-4400
Practice Address - Fax:805-209-4444
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5584213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery