Provider Demographics
NPI:1649017914
Name:LARSON, JONATHAN MATTHEW (MS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:LARSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N 127TH ST E APT 1231
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2772
Mailing Address - Country:US
Mailing Address - Phone:310-748-0355
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST STE 505
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3738
Practice Address - Country:US
Practice Address - Phone:316-688-8390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03266103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical