Provider Demographics
NPI:1891358479
Name:LARSON, KAITLIN JESSICA (DO)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:JESSICA
Last Name:LARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3442
Mailing Address - Country:US
Mailing Address - Phone:626-590-9959
Mailing Address - Fax:
Practice Address - Street 1:18701 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7100
Practice Address - Country:US
Practice Address - Phone:623-561-7983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program