Provider Demographics
NPI:1861813123
Name:LARSSON, JENNIFER THERESA
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:THERESA
Last Name:LARSSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13910 FIVAY RD
Practice Address - Street 2:SUITE 6
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-869-9479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6432235Z00000X
FLSA13294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116523800Medicaid
FLX9DTGOtherBCBS