Provider Demographics
NPI:1932486867
Name:LARSON, JENNIFER (LMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 N SULLIVAN RD
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8546
Mailing Address - Country:US
Mailing Address - Phone:509-924-0504
Mailing Address - Fax:509-340-3732
Practice Address - Street 1:807 N SULLIVAN RD
Practice Address - Street 2:SUITE # 1
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8546
Practice Address - Country:US
Practice Address - Phone:509-924-0504
Practice Address - Fax:509-340-3732
Is Sole Proprietor?:No
Enumeration Date:2011-11-06
Last Update Date:2011-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60194227225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist