Provider Demographics
NPI:1538615943
Name:LARSON, JACOB (OTD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1992 W ANTELOPE DR
Mailing Address - Street 2:SUITE 1-D
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4953
Mailing Address - Country:US
Mailing Address - Phone:801-773-2633
Mailing Address - Fax:
Practice Address - Street 1:1992 W ANTELOPE DR
Practice Address - Street 2:SUITE 1-D
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4953
Practice Address - Country:US
Practice Address - Phone:801-773-2633
Practice Address - Fax:801-773-1553
Is Sole Proprietor?:No
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9829767-4201225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand