Provider Demographics
NPI:1932551801
Name:LARSON, JEREMY R (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N 200 E STE 100
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2500
Mailing Address - Country:US
Mailing Address - Phone:435-288-2880
Mailing Address - Fax:435-522-3290
Practice Address - Street 1:150 N 200 E STE 100
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2500
Practice Address - Country:US
Practice Address - Phone:435-288-2880
Practice Address - Fax:435-522-3290
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12615241-12042084P0802X, 2084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry