Provider Demographics
NPI:1598311458
Name:LARSON, JAMIE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 OVERBROOK RD
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:PA
Mailing Address - Zip Code:16059-1108
Mailing Address - Country:US
Mailing Address - Phone:724-766-9181
Mailing Address - Fax:
Practice Address - Street 1:12300 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8379
Practice Address - Country:US
Practice Address - Phone:724-933-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARBT-17-44761106S00000X
PA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician