Provider Demographics
NPI:1912512856
Name:LARSON, JENNIFER (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 ROANOKE ROAD BOX 429
Mailing Address - Street 2:1454 ROANOKE ROAD
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083
Mailing Address - Country:US
Mailing Address - Phone:540-992-3600
Mailing Address - Fax:540-992-5570
Practice Address - Street 1:1454 ROANOKE RD
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-2935
Practice Address - Country:US
Practice Address - Phone:540-992-3600
Practice Address - Fax:540-992-5570
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily