Provider Demographics
NPI:1184905986
Name:LARSON, JESSICA CAMILLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CAMILLE
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 1:5242 S 4820 W
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-6422
Mailing Address - Country:US
Mailing Address - Phone:801-966-4251
Mailing Address - Fax:801-966-4289
Practice Address - Street 1:350 S 400 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2908
Practice Address - Country:US
Practice Address - Phone:801-582-5534
Practice Address - Fax:801-582-5540
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health