Provider Demographics
NPI:1578995825
Name:LARSON, JANE ELIZABETH
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ELIZABETH
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 1:1500 N 34TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-4477
Mailing Address - Country:US
Mailing Address - Phone:715-392-8216
Mailing Address - Fax:715-392-6055
Practice Address - Street 1:1500 N 34TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4477
Practice Address - Country:US
Practice Address - Phone:715-392-8216
Practice Address - Fax:715-392-6055
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
WI1305271041C0700X
MN258731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant