Provider Demographics
NPI:1629739438
Name:LARSON, JENNIFER MARIA (LSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIA
Last Name:LARSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31979 N FISH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-9517
Mailing Address - Country:US
Mailing Address - Phone:847-201-7066
Mailing Address - Fax:
Practice Address - Street 1:31979 N FISH LAKE RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-9517
Practice Address - Country:US
Practice Address - Phone:847-201-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)