Provider Demographics
NPI:1336205749
Name:VASHON LUTHERAN CHURCH
Entity Type:Organization
Organization Name:VASHON LUTHERAN CHURCH
Other - Org Name:JEFFREY J. LARSON, PH.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:206-463-6359
Mailing Address - Street 1:11628 103RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-3106
Mailing Address - Country:US
Mailing Address - Phone:206-463-6359
Mailing Address - Fax:
Practice Address - Street 1:18623 VASHON HWY SW
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-5211
Practice Address - Country:US
Practice Address - Phone:206-463-6359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3718101YP1600X
WA1608103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty