Provider Demographics
NPI:1083745319
Name:LARSEN, JENNIFER L (RD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:LARSEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4628
Mailing Address - Country:US
Mailing Address - Phone:308-631-5005
Mailing Address - Fax:
Practice Address - Street 1:2101 BOX BUTTE AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-4445
Practice Address - Country:US
Practice Address - Phone:308-761-3416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
756133V00000X
NE756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE923624OtherCLINICAL
NE756OtherMED NUTRITION THERAPIST