Healthcare Provider Details

I. General information

NPI: 1619699352
Provider Name (Legal Business Name): JESSICA BROOKE LARSEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10707 66TH ST N STE B
PINELLAS PARK FL
33782-2353
US

IV. Provider business mailing address

10707 66TH ST N STE B
PINELLAS PARK FL
33782-2353
US

V. Phone/Fax

Practice location:
  • Phone: 727-826-0933
  • Fax: 727-350-3487
Mailing address:
  • Phone: 727-826-0933
  • Fax: 727-350-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11020087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: