Provider Demographics
NPI:1194948232
Name:LARSON, JASON JOSEPH (MED, ATC, EMT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:JOSEPH
Last Name:LARSON
Suffix:
Gender:M
Credentials:MED, ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6562
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-0562
Mailing Address - Country:US
Mailing Address - Phone:609-620-7606
Mailing Address - Fax:609-620-7634
Practice Address - Street 1:2500 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-1600
Practice Address - Country:US
Practice Address - Phone:609-895-2037
Practice Address - Fax:609-620-7634
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000971002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer