Provider Demographics
NPI:1306903885
Name:LARSON, JENNIFER ELLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ELLEN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 ALTAPASS HWY
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-3011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SPRUCE PINE
Practice Address - State:NC
Practice Address - Zip Code:28777-3035
Practice Address - Country:US
Practice Address - Phone:828-765-4201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC014MXOtherBCBS LABS
NC07673OtherBCBS PHYSICIAN
NC00513OtherBCBS
NC235013BOtherMEDICARE PHYSICIAN
NC34U011OtherMEDICARE SWINGBED
NC0081POtherBCBS SWINGBED
NC2061740OtherMEDICARE PHYSICIAN
NC5906586Medicaid
NC8907673OtherMEDICAID PHYSICIAN
NC1479XOtherBCBS INDIVIDUAL PROVIDER
NC235013OtherMEDICARE PHYSICIAN
NC3400011OtherMEDICAID OSCAR
NCCA1796OtherRAILROAD MEDICARE
NC0081POtherBCBS SWINGBED
NC340011Medicare Oscar/Certification