Provider Demographics
NPI:1013444546
Name:LARSEN, JENNIFER LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-6353
Mailing Address - Country:US
Mailing Address - Phone:319-298-5343
Mailing Address - Fax:319-298-5342
Practice Address - Street 1:2115 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-6353
Practice Address - Country:US
Practice Address - Phone:319-298-5343
Practice Address - Fax:319-298-5342
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant