Healthcare Provider Details

I. General information

NPI: 1932551801
Provider Name (Legal Business Name): JEREMY R LARSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N 200 E STE 302
ST GEORGE UT
84770-2899
US

IV. Provider business mailing address

134 N 200 E STE 302
ST GEORGE UT
84770-2899
US

V. Phone/Fax

Practice location:
  • Phone: 435-288-2880
  • Fax: 435-522-3290
Mailing address:
  • Phone: 435-288-2880
  • Fax: 435-522-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number12615241-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number12615241-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: