Healthcare Provider Details

I. General information

NPI: 1750975314
Provider Name (Legal Business Name): JEREMY LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

IV. Provider business mailing address

16225 BEARCREEK LN
CERRITOS CA
90703-2022
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax:
Mailing address:
  • Phone: 920-390-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1420450221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: