Provider Demographics
NPI:1972394005
Name:LARSON, JESSICA LEE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
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 1:4510 77TH ST W
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5505
Mailing Address - Country:US
Mailing Address - Phone:952-826-8475
Mailing Address - Fax:952-922-2525
Practice Address - Street 1:4510 77TH ST W
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5505
Practice Address - Country:US
Practice Address - Phone:952-826-8475
Practice Address - Fax:952-922-2525
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other