Provider Demographics
NPI:1184809907
Name:LARSON, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-3828
Mailing Address - Country:US
Mailing Address - Phone:651-241-1000
Mailing Address - Fax:651-241-1030
Practice Address - Street 1:1026 7TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-3828
Practice Address - Country:US
Practice Address - Phone:651-241-1000
Practice Address - Fax:651-241-1030
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05991363A00000X, 363AS0400X
IL085003026363AS0400X
MN11136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1184809907OtherBLUE CROSS BLUE SHIELD
TX206313302Medicaid
TX206313301Medicaid
TX8DC697OtherBLUE CROSS BLUE SHIELD
TX8Y5543OtherBLUE CROSS BLUE SHIELD
TX206313302Medicaid
TX8L15276Medicare PIN
TX206313301Medicaid