Healthcare Provider Details

I. General information

NPI: 1255163762
Provider Name (Legal Business Name): KORTANI LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3754 DOERING RD
JACKSON MI
49201-9525
US

IV. Provider business mailing address

3754 DOERING RD
JACKSON MI
49201-9525
US

V. Phone/Fax

Practice location:
  • Phone: 517-745-5888
  • Fax:
Mailing address:
  • Phone: 517-745-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: