Provider Demographics
NPI:1629297098
Name:LARSON, JONATHON EUGENE (EDD, CRC, LCPC)
Entity Type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:EUGENE
Last Name:LARSON
Suffix:
Gender:M
Credentials:EDD, CRC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:WINTHROP HARBOR
Mailing Address - State:IL
Mailing Address - Zip Code:60096
Mailing Address - Country:US
Mailing Address - Phone:224-216-0095
Mailing Address - Fax:
Practice Address - Street 1:11316 W WADSWORTH RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60099
Practice Address - Country:US
Practice Address - Phone:224-216-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.0064665101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional