Healthcare Provider Details

I. General information

NPI: 1902248875
Provider Name (Legal Business Name): JENNY LARSON CPM, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER LARSON CPM, RN

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13220 S 154TH ST
GILBERT AZ
85296-4400
US

IV. Provider business mailing address

13220 S 154TH ST
GILBERT AZ
85296-4400
US

V. Phone/Fax

Practice location:
  • Phone: 480-664-7463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number253938
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM197
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: