Provider Demographics
NPI:1962820027
Name:LARSON, JENNIFER CISKE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CISKE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 DEMING WAY DEMING WAY EYE CLINIC
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562
Mailing Address - Country:US
Mailing Address - Phone:608-824-3937
Mailing Address - Fax:608-833-3326
Practice Address - Street 1:2349 DEMING WAY DEMING WAY EYE CLINIC
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562
Practice Address - Country:US
Practice Address - Phone:608-824-3937
Practice Address - Fax:608-833-3326
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64958-20207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology