Provider Demographics
NPI:1881347995
Name:LARSON, JEANIE
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0669
Mailing Address - Country:US
Mailing Address - Phone:701-712-4500
Mailing Address - Fax:701-712-4098
Practice Address - Street 1:2700 STATE ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0669
Practice Address - Country:US
Practice Address - Phone:701-712-4500
Practice Address - Fax:701-712-4098
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR31224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily