Provider Demographics
NPI:1922032085
Name:LARSON, JEANETTE MARIE (MSW)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 SUPERIOR CT STE 103
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6179
Mailing Address - Country:US
Mailing Address - Phone:541-779-8850
Mailing Address - Fax:541-858-5441
Practice Address - Street 1:670 SUPERIOR CT STE 103
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6179
Practice Address - Country:US
Practice Address - Phone:541-779-8850
Practice Address - Fax:541-858-5441
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR13021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
6215OtherUBH
1458749OtherHIPPA
0000TLBPLMedicare ID - Type Unspecified
6215OtherUBH