Provider Demographics
NPI:1609377647
Name:LARSON, JESSICA ANN (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 FULTON ST E APT 4
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist