Healthcare Provider Details

I. General information

NPI: 1184675233
Provider Name (Legal Business Name): JENNIFER LARSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 BROOKS ST STE 101
MISSOULA MT
59801-7338
US

IV. Provider business mailing address

3624 BROOKS ST STE 101
MISSOULA MT
59801-7338
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax:
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6338
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61059800
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number100183
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: