Provider Demographics
NPI:1184937484
Name:LARSEN, JEFFREY KENT (MA MFT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:KENT
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 GOLD OAK CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6754
Mailing Address - Country:US
Mailing Address - Phone:619-207-7005
Mailing Address - Fax:619-271-3123
Practice Address - Street 1:2801 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3800
Practice Address - Country:US
Practice Address - Phone:619-207-7005
Practice Address - Fax:619-271-3123
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC45671101YA0400X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional