Provider Demographics
NPI:1245703503
Name:LARSON, JENNIFER ANN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LLOYD HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11743-9721
Mailing Address - Country:US
Mailing Address - Phone:631-385-1535
Mailing Address - Fax:
Practice Address - Street 1:79 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2200
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105143-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker