Healthcare Provider Details

I. General information

NPI: 1174195986
Provider Name (Legal Business Name): JASON LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N B ST
SACRAMENTO CA
95811-0326
US

IV. Provider business mailing address

1103 N B ST
SACRAMENTO CA
95811-0326
US

V. Phone/Fax

Practice location:
  • Phone: 916-378-8266
  • Fax:
Mailing address:
  • Phone: 916-378-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: