Provider Demographics
NPI:1962904870
Name:LARSEN, JACKIE LYNN (MS-CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LYNN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 MARIAH CT
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-2099
Mailing Address - Country:US
Mailing Address - Phone:715-222-8394
Mailing Address - Fax:
Practice Address - Street 1:329 MARIAH CT
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-2099
Practice Address - Country:US
Practice Address - Phone:715-222-8394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist