Provider Demographics
NPI:1972700433
Name:LARSEN, JILL (BCBA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CENTER
Mailing Address - Street 2:SUITE 151-B
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-993-8096
Mailing Address - Fax:
Practice Address - Street 1:100 CUMMINGS CENTER
Practice Address - Street 2:SUITE 151-B
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915
Practice Address - Country:US
Practice Address - Phone:978-993-8096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1073293103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities