Healthcare Provider Details

I. General information

NPI: 1578995825
Provider Name (Legal Business Name): JANE ELIZABETH LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N 34TH ST SUITE 200
SUPERIOR WI
54880-4477
US

IV. Provider business mailing address

1500 N 34TH ST SUITE 200
SUPERIOR WI
54880-4477
US

V. Phone/Fax

Practice location:
  • Phone: 715-392-8216
  • Fax: 715-392-6055
Mailing address:
  • Phone: 715-392-8216
  • Fax: 715-392-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number130527
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25873
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: