Provider Demographics
NPI:1760691562
Name:LARSEN, JENNIFER EVELYN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:EVELYN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2268 GEORGETOWN CIR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-6729
Mailing Address - Country:US
Mailing Address - Phone:630-290-8119
Mailing Address - Fax:
Practice Address - Street 1:2268 GEORGETOWN CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60503-6729
Practice Address - Country:US
Practice Address - Phone:630-290-8119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist