Healthcare Provider Details

I. General information

NPI: 1174084149
Provider Name (Legal Business Name): JACOB DANIEL LARSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18655 W BERNARDO DR
SAN DIEGO CA
92127-3099
US

IV. Provider business mailing address

222 N PACIFIC COAST HWY STE 1420
EL SEGUNDO CA
90245-5648
US

V. Phone/Fax

Practice location:
  • Phone: 858-939-9914
  • Fax:
Mailing address:
  • Phone: 877-878-3289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58776
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58776
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: