Provider Demographics
NPI:1952610412
Name:LARSON, JENNIFER L (PT, DPT, LMT, CERTDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT, DPT, LMT, CERTDN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, LMT
Mailing Address - Street 1:1309 W GUADALUPE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9112
Mailing Address - Country:US
Mailing Address - Phone:480-280-9625
Mailing Address - Fax:480-718-7628
Practice Address - Street 1:1309 W GUADALUPE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-9112
Practice Address - Country:US
Practice Address - Phone:480-280-9625
Practice Address - Fax:480-718-7628
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9105PT225100000X
AZMT-11128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ560177Medicaid
AZZ146444Medicare PIN