Provider Demographics
NPI:1215521679
Name:LARABEE, JESSICA LYNN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:LARABEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:PANTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:526 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5306
Mailing Address - Country:US
Mailing Address - Phone:269-321-9556
Mailing Address - Fax:
Practice Address - Street 1:526 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5306
Practice Address - Country:US
Practice Address - Phone:269-321-9556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician