Provider Demographics
NPI:1972178952
Name:LARSON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LARSON
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 1:745 CENTURY AVE SW APT 203
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-3736
Mailing Address - Country:US
Mailing Address - Phone:320-405-6467
Mailing Address - Fax:
Practice Address - Street 1:1460 MONTREAL ST SE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-3318
Practice Address - Country:US
Practice Address - Phone:320-587-2509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN819089164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse