Provider Demographics
NPI:1386251163
Name:JEFFREY D LARSON, LLC
Entity type:Organization
Organization Name:JEFFREY D LARSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:612-251-8206
Mailing Address - Street 1:700 RAYMOND AVE SUITE 130
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114
Mailing Address - Country:US
Mailing Address - Phone:612-895-1513
Mailing Address - Fax:
Practice Address - Street 1:700 RAYMOND AVE SUITE 130
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114
Practice Address - Country:US
Practice Address - Phone:612-895-1513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty