Provider Demographics
NPI:1063055192
Name:LARSON, JEROME ALLEN (PSS)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:ALLEN
Last Name:LARSON
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 N 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1617
Mailing Address - Country:US
Mailing Address - Phone:414-254-4291
Mailing Address - Fax:
Practice Address - Street 1:3090 N 53RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1617
Practice Address - Country:US
Practice Address - Phone:414-254-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist