Provider Demographics
NPI:1326179177
Name:LARSON, JEFFREY J (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11628 103RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-3106
Mailing Address - Country:US
Mailing Address - Phone:206-463-6359
Mailing Address - Fax:
Practice Address - Street 1:18623 VASHON HWY SW
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-5211
Practice Address - Country:US
Practice Address - Phone:206-463-6359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3718101YP1600X
WA1608103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical