Healthcare Provider Details

I. General information

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

Provider Other Name: JENNY LARSON DNP, CNM, CPM

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 W MAIN ST
MESA AZ
85201-6920
US

IV. Provider business mailing address

3033 N CENTRAL AVE STE 145
PHOENIX AZ
85012-2808
US

V. Phone/Fax

Practice location:
  • Phone: 480-964-2273
  • Fax: 480-718-9477
Mailing address:
  • Phone: 623-583-3001
  • Fax: 623-974-6721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number253938
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number253938
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM197
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: