Provider Demographics
NPI:1780453647
Name:LARSEN, JEREMY SCOTT
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8072 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5037
Mailing Address - Country:US
Mailing Address - Phone:385-351-5483
Mailing Address - Fax:
Practice Address - Street 1:8072 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-5037
Practice Address - Country:US
Practice Address - Phone:385-351-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)