Healthcare Provider Details

I. General information

NPI: 1629297098
Provider Name (Legal Business Name): JONATHON EUGENE LARSON ED.D., CRC, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11316 W WADSWORTH RD SUITE 102
BEACH PARK IL
60099
US

IV. Provider business mailing address

920 WASHINGTON AVENUE
WINTHROP HARBOR IL
60096
US

V. Phone/Fax

Practice location:
  • Phone: 224-216-0095
  • Fax:
Mailing address:
  • Phone: 224-216-0095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.0064665
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: