Healthcare Provider Details

I. General information

NPI: 1336422708
Provider Name (Legal Business Name): JILL M LARSON BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 ROUTE 2A
PRESTON CT
06365-8537
US

IV. Provider business mailing address

124 ROUTE 2A
PRESTON CT
06365-8537
US

V. Phone/Fax

Practice location:
  • Phone: 612-232-8367
  • Fax:
Mailing address:
  • Phone: 612-232-8367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009138
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18215
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: