Provider Demographics
NPI:1427828425
Name:LARSEN, JENNIFER L (LPC-IT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W CAPITOL DR APT 11
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1909
Mailing Address - Country:US
Mailing Address - Phone:262-631-9930
Mailing Address - Fax:
Practice Address - Street 1:375 WILLIAMSTOWNE STE L11
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2331
Practice Address - Country:US
Practice Address - Phone:262-631-9930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI7740101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health