Healthcare Provider Details

I. General information

NPI: 1477595536
Provider Name (Legal Business Name): JESSICA LARSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: JESSICA NICHOLSON MD

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 MAIN ST NW
ELK RIVER MN
55330-1270
US

IV. Provider business mailing address

27060 136TH ST
ZIMMERMAN MN
55398-9300
US

V. Phone/Fax

Practice location:
  • Phone: 763-241-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46376
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: