Healthcare Provider Details

I. General information

NPI: 1548050594
Provider Name (Legal Business Name): JASON LARSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 NICOLLET AVE
MINNEAPOLIS MN
55409-1304
US

IV. Provider business mailing address

3808 NICOLLET AVE
MINNEAPOLIS MN
55409-1304
US

V. Phone/Fax

Practice location:
  • Phone: 612-369-7494
  • Fax: 612-225-1869
Mailing address:
  • Phone: 612-369-7494
  • Fax: 612-225-1869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number2484939
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: