Provider Demographics
NPI:1104232800
Name:LARSON, JESSICA (BS, BS, MAFP, CSAC)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:BS, BS, MAFP, CSAC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:LENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, BS, MAFP
Mailing Address - Street 1:230 W WELLS ST STE 312
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1837
Mailing Address - Country:US
Mailing Address - Phone:414-344-3406
Mailing Address - Fax:414-344-0107
Practice Address - Street 1:230 W WELLS ST STE 312
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1837
Practice Address - Country:US
Practice Address - Phone:414-344-3406
Practice Address - Fax:414-344-0107
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16009-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100055295Medicaid