Provider Demographics
NPI:1972755940
Name:LARSEN, JO ANN (DSW)
Entity type:Individual
Prefix:DR
First Name:JO
Middle Name:ANN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:DSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E 8400 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-0525
Mailing Address - Country:US
Mailing Address - Phone:801-566-2556
Mailing Address - Fax:801-566-2639
Practice Address - Street 1:625 E 8400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-0525
Practice Address - Country:US
Practice Address - Phone:801-566-2556
Practice Address - Fax:801-566-2639
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1037843501106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000007995Medicare UPIN