Provider Demographics
NPI:1285684555
Name:LARSON, JENNIFER RUTH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RUTH
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:21195 RADISSON RD
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55331-9189
Mailing Address - Country:US
Mailing Address - Phone:952-470-3976
Mailing Address - Fax:
Practice Address - Street 1:1515 SAINT FRANCIS AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3387
Practice Address - Country:US
Practice Address - Phone:952-403-3399
Practice Address - Fax:952-403-3390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2022-11-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN9789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN216702600Medicaid