Provider Demographics
NPI:1932360906
Name:LARUSSO, JENNIFER LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:LARUSSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 CROWS NEST CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-6109
Mailing Address - Country:US
Mailing Address - Phone:856-273-5811
Mailing Address - Fax:
Practice Address - Street 1:771 E ROUTE 70
Practice Address - Street 2:SUITE D150
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2352
Practice Address - Country:US
Practice Address - Phone:856-569-3393
Practice Address - Fax:856-596-3394
Is Sole Proprietor?:No
Enumeration Date:2008-06-22
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013778207N00000X, 207ND0101X
NJ25MB07507100207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA221297Medicare PIN
NJI19280Medicare UPIN