Provider Demographics
NPI:1104416197
Name:LARSEN, JESSICA (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 SE CRYSTAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-2014
Mailing Address - Country:US
Mailing Address - Phone:917-679-7296
Mailing Address - Fax:
Practice Address - Street 1:2405 SE CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-2014
Practice Address - Country:US
Practice Address - Phone:917-679-7296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist