Provider Demographics
NPI:1144702622
Name:LARSON, JENNIFER KATHRYN (MA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KATHRYN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 PHEASANT RIDGE DR NE STE 412
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5066
Mailing Address - Country:US
Mailing Address - Phone:763-703-3754
Mailing Address - Fax:372-703-3725
Practice Address - Street 1:4255 PHEASANT RIDGE DR NE STE 412
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5066
Practice Address - Country:US
Practice Address - Phone:763-703-3754
Practice Address - Fax:372-703-3725
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist